Provider Demographics
NPI:1881839835
Name:ACTIVE LIFE CHIROPRACTIC CENTER, INC.
Entity Type:Organization
Organization Name:ACTIVE LIFE CHIROPRACTIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:CHAMBERLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-229-2649
Mailing Address - Street 1:259 S 2670 E
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-6412
Mailing Address - Country:US
Mailing Address - Phone:435-229-2649
Mailing Address - Fax:435-674-7565
Practice Address - Street 1:676 S BLUFF ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3596
Practice Address - Country:US
Practice Address - Phone:435-674-7515
Practice Address - Fax:435-674-7565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7154097-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty