Provider Demographics
NPI:1932577160
Name:ACTIVE SPINE CHIROPRACTIC, P.A.
Entity Type:Organization
Organization Name:ACTIVE SPINE CHIROPRACTIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WITTGREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:786-759-6265
Mailing Address - Street 1:2421 NE 65TH ST
Mailing Address - Street 2:307
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-1556
Mailing Address - Country:US
Mailing Address - Phone:786-759-6265
Mailing Address - Fax:
Practice Address - Street 1:1255 N FLAGLER DR
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-2131
Practice Address - Country:US
Practice Address - Phone:786-759-6265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10100111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty