Provider Demographics
NPI:1457797557
Name:ACTIVE HEALTH CARE, PA
Entity Type:Organization
Organization Name:ACTIVE HEALTH CARE, PA
Other - Org Name:ACTIVE CHIROPRACTIC MEDICINE AND SOFT TISSUE, P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LIPP
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DACBSP
Authorized Official - Phone:904-296-0202
Mailing Address - Street 1:6500 BOWDEN RD
Mailing Address - Street 2:200
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8070
Mailing Address - Country:US
Mailing Address - Phone:904-296-0202
Mailing Address - Fax:
Practice Address - Street 1:6500 BOWDEN RD
Practice Address - Street 2:200
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8070
Practice Address - Country:US
Practice Address - Phone:904-296-0202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HT208AOtherMEDICARE PTAN