Provider Demographics
NPI:1447454277
Name:ACTIVE CHIROPRACTIC, INC
Entity type:Organization
Organization Name:ACTIVE CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:804-378-6035
Mailing Address - Street 1:2900 POLO PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-1423
Mailing Address - Country:US
Mailing Address - Phone:804-378-6035
Mailing Address - Fax:804-560-9360
Practice Address - Street 1:2900 POLO PKWY STE 101
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-1423
Practice Address - Country:US
Practice Address - Phone:804-378-6035
Practice Address - Fax:804-560-9360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556304111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10315Medicare PIN