Provider Demographics
NPI:1780851279
Name:ACTIVE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:ACTIVE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-568-9923
Mailing Address - Street 1:1706 YORK ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BLOOMER
Mailing Address - State:WI
Mailing Address - Zip Code:54724-1920
Mailing Address - Country:US
Mailing Address - Phone:715-568-9923
Mailing Address - Fax:715-568-9924
Practice Address - Street 1:1706 YORK ST
Practice Address - Street 2:SUITE 5
Practice Address - City:BLOOMER
Practice Address - State:WI
Practice Address - Zip Code:54724-1920
Practice Address - Country:US
Practice Address - Phone:715-568-9923
Practice Address - Fax:715-568-9924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4151-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty