Provider Demographics
NPI:1144247818
Name:ACTIVE LIFE CHIROPRACTIC CENTER
Entity type:Organization
Organization Name:ACTIVE LIFE CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:B
Authorized Official - Last Name:RIEDEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:440-466-1155
Mailing Address - Street 1:614 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:OH
Mailing Address - Zip Code:44041-1385
Mailing Address - Country:US
Mailing Address - Phone:440-466-1155
Mailing Address - Fax:440-466-1255
Practice Address - Street 1:614 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:OH
Practice Address - Zip Code:44041-1385
Practice Address - Country:US
Practice Address - Phone:440-466-1155
Practice Address - Fax:440-466-1255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3328111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPO0199838OtherRAILROAD MEDICARE
OHSP04811Medicare ID - Type Unspecified