1164642765 NPI number — ACTIVE HEALTH SERVICES

Table of content: (NPI 1164642765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164642765 NPI number — ACTIVE HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE HEALTH SERVICES
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:
1164642765
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1844
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75221-1844
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-220-9177
Provider Business Mailing Address Fax Number:
214-220-0410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1717 MAIN ST STE 5640
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75201-7348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
241-220-9117
Provider Business Practice Location Address Fax Number:
214-220-0410
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
FLEMING
Authorized Official Title or Position:
CHIROPRACTOR OWNER
Authorized Official Telephone Number:
214-220-3177

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  6026 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6026 . This is a "LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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