Provider Demographics
NPI:1548574494
Name:ACTIVE CHIROPRACTIC, PSC
Entity type:Organization
Organization Name:ACTIVE CHIROPRACTIC, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:TRUE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:606-676-0040
Mailing Address - Street 1:111 W HIGHWAY 80
Mailing Address - Street 2:STE. B
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2725
Mailing Address - Country:US
Mailing Address - Phone:606-676-0040
Mailing Address - Fax:606-676-0641
Practice Address - Street 1:111 W HIGHWAY 80
Practice Address - Street 2:STE B
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2725
Practice Address - Country:US
Practice Address - Phone:606-676-0040
Practice Address - Fax:606-676-0641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-03
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4917111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty