Healthcare Provider Details

I. General information

NPI: 1538452859
Provider Name (Legal Business Name): ACTIVE HEALTH CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2011
Last Update Date: 06/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

371 N 9TH AVE
SCRANTON PA
18504-2005
US

IV. Provider business mailing address

371 N 9TH AVE
SCRANTON PA
18504-2005
US

V. Phone/Fax

Practice location:
  • Phone: 570-558-2225
  • Fax: 570-558-6325
Mailing address:
  • Phone: 570-558-2225
  • Fax: 570-558-6325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberDC008926
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. CHRISTINE M. KMIEC
Title or Position: DR.
Credential: D.C.
Phone: 570-558-2225