Provider Demographics
NPI:1760520092
Name:ACTIVELIFE FAMILY CHIROPRACTIC CENTER, INC.
Entity Type:Organization
Organization Name:ACTIVELIFE FAMILY CHIROPRACTIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:614-866-5181
Mailing Address - Street 1:13299 SUMMERFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-9251
Mailing Address - Country:US
Mailing Address - Phone:614-866-5181
Mailing Address - Fax:
Practice Address - Street 1:13299 SUMMERFIELD WAY
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-9251
Practice Address - Country:US
Practice Address - Phone:614-866-5181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2117111N00000X
OH2191111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
074684048004OtherMMO
509743928004OtherMMO LISA
OH000000120889OtherANTHEM
4400103OtherUHC GROUP
000000120890OtherANTHEM - LISA
OH0229050Medicaid
4400103OtherUHC GROUP
U56408Medicare UPIN
509743928004OtherMMO LISA