Healthcare Provider Details

I. General information

NPI: 1346293966
Provider Name (Legal Business Name): ACTIVE CHIROPRACTIC CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 S I 75 BUSINESS LOOP
GRAYLING MI
49738-2022
US

IV. Provider business mailing address

PO BOX 401
GRAYLING MI
49738-0401
US

V. Phone/Fax

Practice location:
  • Phone: 989-348-4560
  • Fax: 989-348-1663
Mailing address:
  • Phone: 989-348-4560
  • Fax: 989-348-1663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301008135
License Number StateMI

VIII. Authorized Official

Name: LAURIE WOODRUFF
Title or Position: OWNER/PRESIDENT
Credential: DC
Phone: 989-348-4560