Provider Demographics
NPI:1891090395
Name:ACTIVE FAMILY CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:ACTIVE FAMILY CHIROPRACTIC, LLC
Other - Org Name:CARDINAL PHYSICAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BLALOCK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:636-352-0380
Mailing Address - Street 1:1404 TRIAD CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-7351
Mailing Address - Country:US
Mailing Address - Phone:636-352-0380
Mailing Address - Fax:636-352-2343
Practice Address - Street 1:1404 TRIAD CENTER DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-7351
Practice Address - Country:US
Practice Address - Phone:636-352-0380
Practice Address - Fax:636-352-2343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-14
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011000744261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center