Provider Demographics
NPI:1902826845
Name:ACTIVE SPINE CENTER OF HOMESTEAD, INC
Entity Type:Organization
Organization Name:ACTIVE SPINE CENTER OF HOMESTEAD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:LOPATE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:305-242-6665
Mailing Address - Street 1:33550 S DIXIE HWY
Mailing Address - Street 2:SUITE 132
Mailing Address - City:FLORIDA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33034-5602
Mailing Address - Country:US
Mailing Address - Phone:305-242-6665
Mailing Address - Fax:305-242-6919
Practice Address - Street 1:33550 S DIXIE HWY
Practice Address - Street 2:SUITE 132
Practice Address - City:FLORIDA CITY
Practice Address - State:FL
Practice Address - Zip Code:33034-5602
Practice Address - Country:US
Practice Address - Phone:305-242-6665
Practice Address - Fax:305-242-6919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8338111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL382025400Medicaid
FL382091200Medicaid
FLU80312Medicare UPIN
FL382091200Medicaid