Provider Demographics
NPI:1174877955
Name:ACTIVE LIFE CHIROPRACTIC CLINIC LLC
Entity type:Organization
Organization Name:ACTIVE LIFE CHIROPRACTIC CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR/OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:COPPOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-965-9820
Mailing Address - Street 1:609 S 48TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3614
Mailing Address - Country:US
Mailing Address - Phone:509-965-9820
Mailing Address - Fax:509-965-9822
Practice Address - Street 1:609 S 48TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3614
Practice Address - Country:US
Practice Address - Phone:509-965-9820
Practice Address - Fax:509-965-9822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60309681111NP0017X, 111NS0005X
WACH60309678111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Multi-Specialty