Provider Demographics
NPI:1558543751
Name:ACTIVE LIFE CHIROPRACTIC AND SPORT LLC
Entity Type:Organization
Organization Name:ACTIVE LIFE CHIROPRACTIC AND SPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HALLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-225-1017
Mailing Address - Street 1:600 UNION ST S
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-1870
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 UNION ST S
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1870
Practice Address - Country:US
Practice Address - Phone:320-225-1017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4735111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty