Healthcare Provider Details

I. General information

NPI: 1255682761
Provider Name (Legal Business Name): ACTIVE HEALTHCARE OF NELSONVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2012
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1259 E CANAL ST
NELSONVILLE OH
45764-8000
US

IV. Provider business mailing address

1259 E CANAL ST
NELSONVILLE OH
45764-8000
US

V. Phone/Fax

Practice location:
  • Phone: 740-753-1902
  • Fax: 740-753-4233
Mailing address:
  • Phone: 740-753-1902
  • Fax: 740-753-4233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2400
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: TERESA ANN HINE
Title or Position: OFFICE MANAGER
Credential:
Phone: 740-753-1902