Healthcare Provider Details

I. General information

NPI: 1073066353
Provider Name (Legal Business Name): ACTIVE WELLNESS CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 N SCOTTSDALE RD
SCOTTSDALE AZ
85257-2119
US

IV. Provider business mailing address

1920 N SCOTTSDALE RD
SCOTTSDALE AZ
85257-2119
US

V. Phone/Fax

Practice location:
  • Phone: 480-994-0072
  • Fax:
Mailing address:
  • Phone: 480-994-0072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number8565
License Number StateAZ

VIII. Authorized Official

Name: BRIAN LUEDKE
Title or Position: OWNER
Credential: DC
Phone: 319-427-0003