Provider Demographics
NPI:1912220690
Name:ACTIVE LIVING CHIROPRACTIC INC
Entity Type:Organization
Organization Name:ACTIVE LIVING CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/WIFE
Authorized Official - Prefix:MRS
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:BULLOCK
Authorized Official - Last Name:WIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-756-6111
Mailing Address - Street 1:704 E. ARLINGTON BLVD.
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858
Mailing Address - Country:US
Mailing Address - Phone:252-756-6111
Mailing Address - Fax:252-756-6904
Practice Address - Street 1:704 E. ARLINGTON BLVD.
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858
Practice Address - Country:US
Practice Address - Phone:252-756-6111
Practice Address - Fax:252-756-6904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4057111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4057OtherNC CHIROPRACTIC LICENSE