Provider Demographics
NPI:1831883099
Name:ACTIVE BODY CHIRO REHAB
Entity type:Organization
Organization Name:ACTIVE BODY CHIRO REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-346-7412
Mailing Address - Street 1:733 ROOSEVELT TRL STE 1
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-5286
Mailing Address - Country:US
Mailing Address - Phone:207-346-7412
Mailing Address - Fax:
Practice Address - Street 1:733 ROOSEVELT TRL STE 1
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-5286
Practice Address - Country:US
Practice Address - Phone:207-346-7412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty