Provider Demographics
NPI:1942446109
Name:ACTIVE LIFE CHIROPRACTIC & REHABILITATION PC
Entity Type:Organization
Organization Name:ACTIVE LIFE CHIROPRACTIC & REHABILITATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:RHETT
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:BRUNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:615-480-2056
Mailing Address - Street 1:11227 LEBANON RD
Mailing Address - Street 2:
Mailing Address - City:MT. JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122
Mailing Address - Country:US
Mailing Address - Phone:615-480-2056
Mailing Address - Fax:
Practice Address - Street 1:11227 LEBANON RD
Practice Address - Street 2:
Practice Address - City:MT. JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122
Practice Address - Country:US
Practice Address - Phone:615-480-2056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2317111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty