Healthcare Provider Details

I. General information

NPI: 1992945182
Provider Name (Legal Business Name): ACTIVE FAMILY CHIROPRACTIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 SOUTH ST
GREEN LAKE WI
54941-9496
US

IV. Provider business mailing address

PO BOX 163
GREEN LAKE WI
54941-0163
US

V. Phone/Fax

Practice location:
  • Phone: 920-229-7215
  • Fax:
Mailing address:
  • Phone: 920-229-7215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateWI

VIII. Authorized Official

Name: ANDREA M KING
Title or Position: OWNER
Credential: DC
Phone: 920-229-7215