Healthcare Provider Details

I. General information

NPI: 1922003847
Provider Name (Legal Business Name): ACTIVE LIFE CHIROPRACTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 LOGAN ST STE 101
NOBLESVILLE IN
46060-2225
US

IV. Provider business mailing address

920 LOGAN ST STE 101
NOBLESVILLE IN
46060-2225
US

V. Phone/Fax

Practice location:
  • Phone: 317-776-3313
  • Fax: 317-776-3312
Mailing address:
  • Phone: 317-776-3313
  • Fax: 317-776-3312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08002172A
License Number StateIN

VIII. Authorized Official

Name: DR. ELIZABETH KRUEGER
Title or Position: PRESIDENT
Credential: D.C.
Phone: 317-776-3313