Provider Demographics
NPI:1548348956
Name:ACTIVE CHIROPRACTIC WELLNESS CENTER
Entity type:Organization
Organization Name:ACTIVE CHIROPRACTIC WELLNESS CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:TELAYA
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:719-636-3080
Mailing Address - Street 1:2790 N. ACADEMY BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5300
Mailing Address - Country:US
Mailing Address - Phone:719-636-3080
Mailing Address - Fax:
Practice Address - Street 1:2790 N. ACADEMY BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5300
Practice Address - Country:US
Practice Address - Phone:719-636-3080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5728111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty