Provider Demographics
NPI:1821116625
Name:ACTIVE HEALTH CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:ACTIVE HEALTH CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-480-1852
Mailing Address - Street 1:3525 ELLICOTT MILLS DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-4547
Mailing Address - Country:US
Mailing Address - Phone:410-480-1852
Mailing Address - Fax:410-480-1857
Practice Address - Street 1:3525 ELLICOTT MILLS DR
Practice Address - Street 2:SUITE F
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-4547
Practice Address - Country:US
Practice Address - Phone:410-480-1852
Practice Address - Fax:410-480-1857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKCC4OtherCAREFIRST
MDF852OtherCAREFIRST DC
MDKCC4OtherCAREFIRST
MDU83899Medicare UPIN