Provider Demographics
NPI:1740532597
Name:ACTIVE LIFE CHIROPRACTIC
Entity type:Organization
Organization Name:ACTIVE LIFE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALESHA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:404-790-5664
Mailing Address - Street 1:PO BOX 630821
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80163-0821
Mailing Address - Country:US
Mailing Address - Phone:404-790-5664
Mailing Address - Fax:720-306-8987
Practice Address - Street 1:9370 S COLORADO BLVD
Practice Address - Street 2:#A-10
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80126-5205
Practice Address - Country:US
Practice Address - Phone:303-471-9355
Practice Address - Fax:720-306-8987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty