Provider Demographics
NPI:1700096989
Name:ACTIVE HEALTH CHIROPRACTIC CLINIC, P.C.
Entity Type:Organization
Organization Name:ACTIVE HEALTH CHIROPRACTIC CLINIC, P.C.
Other - Org Name:ACTIVE HEALTH CHIROPRACTIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:319-627-6461
Mailing Address - Street 1:1103 N ELM ST
Mailing Address - Street 2:STE 102
Mailing Address - City:WEST LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52776-1006
Mailing Address - Country:US
Mailing Address - Phone:319-627-6461
Mailing Address - Fax:
Practice Address - Street 1:1103 N ELM ST
Practice Address - Street 2:STE 102
Practice Address - City:WEST LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52776-1006
Practice Address - Country:US
Practice Address - Phone:319-627-6461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06934111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA29848OtherWELLMARK BCBS
NE099789Medicare ID - Type Unspecified