1013094291 NPI number — ACTIVE CHIROPRACTIC LIMITED LIABILITY COMPANY PA

Table of content: (NPI 1013094291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013094291 NPI number — ACTIVE CHIROPRACTIC LIMITED LIABILITY COMPANY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE CHIROPRACTIC LIMITED LIABILITY COMPANY PA
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:
Provider Other Organization Name Type Code:
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:
1013094291
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
439 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
SACO
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04072-1528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-571-8028
Provider Business Mailing Address Fax Number:
866-213-8207

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
439 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
SACO
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04072-1528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-571-8028
Provider Business Practice Location Address Fax Number:
866-213-8207
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REICHE
Authorized Official First Name:
BRENT
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
207-571-8028

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CR1313 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: U56702 . This is a "HARVARD PILGRAM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 0020752 . This is a "MEDICARE PTAN" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 022530 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 05Z044016ME02 . This is a "FEDERAL EMPLOYEE PLANS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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