Healthcare Provider Details

I. General information

NPI: 1720422462
Provider Name (Legal Business Name): ACTIVE CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 SOLOMONS ISLAND ROAD SUITE 201
ANNAPOLIS MD
21401-3852
US

IV. Provider business mailing address

43 SOLOMONS ISLAND ROAD SUITE 201
ANNAPOLIS MD
21401-3852
US

V. Phone/Fax

Practice location:
  • Phone: 410-266-3888
  • Fax:
Mailing address:
  • Phone: 410-266-3888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberS03744
License Number StateMD

VIII. Authorized Official

Name: DR. ANDREW GEORGE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: D.C.
Phone: 937-689-4601