Provider Demographics
NPI:1780865311
Name:PRO ACTIVE CHIROPRACTIC GROUP INC
Entity Type:Organization
Organization Name:PRO ACTIVE CHIROPRACTIC GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUESSLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-685-7734
Mailing Address - Street 1:4591 E HIGHWAY 20 STE 201
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8845
Mailing Address - Country:US
Mailing Address - Phone:850-279-4913
Mailing Address - Fax:850-279-4975
Practice Address - Street 1:4591 E HIGHWAY 20 STE 201
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8845
Practice Address - Country:US
Practice Address - Phone:850-279-4913
Practice Address - Fax:850-279-4975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 8262111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381477700Medicaid
FLU79875Medicare UPIN