1922540301 NPI number — ACTIVE CHIROPRACTIC AND WELLNESS

Table of content: (NPI 1922540301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922540301 NPI number — ACTIVE CHIROPRACTIC AND WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE CHIROPRACTIC AND WELLNESS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NESIBA MATTSON CHIROPRACTIC AND WELLNESS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922540301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 BUCKSPORT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLSWORTH
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04605-2224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-667-4678
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 BUCKSPORT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLSWORTH
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04605-2224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-667-4678
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MATTSON
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
207-667-4578

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CR1906 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111N00000X , with the licence number: CR2315 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171100000X , with the licence number: AC526 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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