Provider Demographics
NPI:1952506206
Name:HEALTHY AND ACTIVE
Entity Type:Organization
Organization Name:HEALTHY AND ACTIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:BYSIEK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:201-444-6700
Mailing Address - Street 1:29 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07401-1511
Mailing Address - Country:US
Mailing Address - Phone:201-444-6700
Mailing Address - Fax:
Practice Address - Street 1:29 HIGH ST
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:NJ
Practice Address - Zip Code:07401-1511
Practice Address - Country:US
Practice Address - Phone:201-444-6700
Practice Address - Fax:201-327-3828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00592500111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ087213Medicare ID - Type UnspecifiedGRP
NJ087049 TQUMedicare ID - Type UnspecifiedINDIV AND GRPSUFF