Provider Demographics
NPI:1922540301
Name:ACTIVE CHIROPRACTIC AND WELLNESS
Entity Type:Organization
Organization Name:ACTIVE CHIROPRACTIC AND WELLNESS
Other - Org Name:NESIBA MATTSON CHIROPRACTIC AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-667-4578
Mailing Address - Street 1:150 BUCKSPORT RD
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-2224
Mailing Address - Country:US
Mailing Address - Phone:207-667-4678
Mailing Address - Fax:
Practice Address - Street 1:150 BUCKSPORT RD
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-2224
Practice Address - Country:US
Practice Address - Phone:207-667-4678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1906111N00000X
MECR2315111N00000X
MEAC526171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty