Provider Demographics
NPI:1982850830
Name:ACTIVE CHIROPRACTIC WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:ACTIVE CHIROPRACTIC WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:RENNE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-398-4860
Mailing Address - Street 1:2570 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-3604
Mailing Address - Country:US
Mailing Address - Phone:904-226-9110
Mailing Address - Fax:904-398-1785
Practice Address - Street 1:2570 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-3604
Practice Address - Country:US
Practice Address - Phone:904-398-4860
Practice Address - Fax:904-398-1785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7715111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty