Provider Demographics
NPI:1922496637
Name:ACTIVE EDGE CHIROPRACTIC & REHAB
Entity Type:Organization
Organization Name:ACTIVE EDGE CHIROPRACTIC & REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:217-222-6500
Mailing Address - Street 1:1024 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4039
Mailing Address - Country:US
Mailing Address - Phone:217-222-6500
Mailing Address - Fax:217-222-5688
Practice Address - Street 1:1024 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4039
Practice Address - Country:US
Practice Address - Phone:217-222-6500
Practice Address - Fax:217-222-5688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.012516111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty