Provider Demographics
NPI:1831336544
Name:ACTIVE HEALTH CENTER, PC
Entity type:Organization
Organization Name:ACTIVE HEALTH CENTER, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HANDCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:512-310-2747
Mailing Address - Street 1:1713 S MAYS ST STE A
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-6738
Mailing Address - Country:US
Mailing Address - Phone:512-310-2747
Mailing Address - Fax:512-310-2759
Practice Address - Street 1:1713 S MAYS ST STE A
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-6738
Practice Address - Country:US
Practice Address - Phone:512-310-2747
Practice Address - Fax:512-310-2759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5351111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A4990OtherMEDICARE GROUP PTAN
TXC06035727Medicaid
TXC06035727Medicaid