Provider Demographics
NPI:1588810782
Name:ACTIVE CHIROPRACTIC AND WELLNESS CENTER
Entity Type:Organization
Organization Name:ACTIVE CHIROPRACTIC AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROMEO
Authorized Official - Middle Name:ECLAVEA
Authorized Official - Last Name:DIMAANO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:805-384-0101
Mailing Address - Street 1:2440 LAS POSAS RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-3458
Mailing Address - Country:US
Mailing Address - Phone:805-384-0101
Mailing Address - Fax:805-384-0220
Practice Address - Street 1:2440 LAS POSAS RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-3458
Practice Address - Country:US
Practice Address - Phone:805-384-0101
Practice Address - Fax:805-384-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-30203111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC30203Medicare PIN