Healthcare Provider Details

I. General information

NPI: 1336395771
Provider Name (Legal Business Name): ACTIVE HEALTH CONCEPTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 237TH ST UNIT B
HARBOR CITY CA
90710-1324
US

IV. Provider business mailing address

1601 237TH ST UNIT B
HARBOR CITY CA
90710-1324
US

V. Phone/Fax

Practice location:
  • Phone: 310-218-8106
  • Fax: 310-325-6138
Mailing address:
  • Phone: 310-218-8106
  • Fax: 310-325-6138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC 28271
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License NumberDC 28271
License Number StateCA

VIII. Authorized Official

Name: DR. ALAN PAN
Title or Position: OWNER
Credential: DC
Phone: 310-218-8106