Provider Demographics
NPI:1326354077
Name:ACTIVE CHIROPRACTIC CLINIC LLC
Entity type:Organization
Organization Name:ACTIVE CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:CASSELLIUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-783-3307
Mailing Address - Street 1:419 SAND LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-2706
Mailing Address - Country:US
Mailing Address - Phone:608-783-3307
Mailing Address - Fax:608-779-9728
Practice Address - Street 1:419 SAND LAKE RD
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-2706
Practice Address - Country:US
Practice Address - Phone:608-783-3307
Practice Address - Fax:608-779-9728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2239111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty