Healthcare Provider Details

I. General information

NPI: 1336423334
Provider Name (Legal Business Name): ACTIVE FAMILY & SPORTS CHIROPRACTIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2011
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 GALLAHER RD SUITE B & C
KINGSTON TN
37763-4139
US

IV. Provider business mailing address

1260 GALLAHER RD SUITE B & C
KINGSTON TN
37763-4139
US

V. Phone/Fax

Practice location:
  • Phone: 865-382-3014
  • Fax: 865-248-8215
Mailing address:
  • Phone: 865-248-8167
  • Fax: 865-248-8215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2547
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number2547
License Number StateTN

VIII. Authorized Official

Name: DR. JUDE AARON MILLER
Title or Position: OWNER/CLINIC DIRECTOR
Credential: DC, MS
Phone: 865-248-8167