Provider Demographics
NPI:1578867727
Name:ACTIVE HEALTH CHIROPRACTIC
Entity Type:Organization
Organization Name:ACTIVE HEALTH CHIROPRACTIC
Other - Org Name:ACTIVE HEALTH FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUAL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-470-2020
Mailing Address - Street 1:116 4TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-1312
Mailing Address - Country:US
Mailing Address - Phone:218-470-2020
Mailing Address - Fax:
Practice Address - Street 1:116 4TH AVE N
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-1312
Practice Address - Country:US
Practice Address - Phone:218-470-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5247111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty