1457535973 NPI number — ACTIVE BODY CHIROPRACTIC AND INJURY CENTER PLLC

Table of content: (NPI 1457535973)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457535973 NPI number — ACTIVE BODY CHIROPRACTIC AND INJURY CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE BODY CHIROPRACTIC AND INJURY CENTER PLLC
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:
6
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:
1457535973
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
507 JOSEPH DR.
Provider Second Line Business Mailing Address:
STE. 4
Provider Business Mailing Address City Name:
HARRODSBURG
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-734-2800
Provider Business Mailing Address Fax Number:
859-734-2805

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
507 JOSEPH DR.
Provider Second Line Business Practice Location Address:
STE. 4
Provider Business Practice Location Address City Name:
HARRODSBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-734-2800
Provider Business Practice Location Address Fax Number:
859-734-2805
Provider Enumeration Date:
12/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCCORMACK
Authorized Official First Name:
TOSHA
Authorized Official Middle Name:
Authorized Official Title or Position:
COMPLIANCE OFFICER
Authorized Official Telephone Number:
859-408-5440

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100293130 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00759001 . This is a "MEDICARE PTIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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