Provider Demographics
NPI:1922003847
Name:ACTIVE LIFE CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:ACTIVE LIFE CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-776-3313
Mailing Address - Street 1:920 LOGAN ST
Mailing Address - Street 2:STE 101
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-2225
Mailing Address - Country:US
Mailing Address - Phone:317-776-3313
Mailing Address - Fax:317-776-3312
Practice Address - Street 1:920 LOGAN ST
Practice Address - Street 2:STE 101
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-2225
Practice Address - Country:US
Practice Address - Phone:317-776-3313
Practice Address - Fax:317-776-3312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002172A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INV04095Medicare UPIN
IN224200AMedicare ID - Type Unspecified