Provider Demographics
NPI:1801053517
Name:ACTIVE LIFE CHIROPRACTIC CENTER, LTD
Entity type:Organization
Organization Name:ACTIVE LIFE CHIROPRACTIC CENTER, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLININC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-443-3965
Mailing Address - Street 1:103 E 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-5034
Mailing Address - Country:US
Mailing Address - Phone:406-443-3965
Mailing Address - Fax:406-443-3964
Practice Address - Street 1:103 E 6TH AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-5034
Practice Address - Country:US
Practice Address - Phone:406-443-3965
Practice Address - Fax:406-443-3964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1136111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT41573OtherBLUE CROSS/BLUE SHIELD