=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013094291
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACTIVE CHIROPRACTIC LIMITED LIABILITY COMPANY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 07/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 439 MAIN ST SUITE 104
-----------------------------------------------------
City | SACO
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04072-1528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-571-8028
-----------------------------------------------------
Fax | 866-213-8207
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 439 MAIN ST SUITE 104
-----------------------------------------------------
City | SACO
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04072-1528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-571-8028
-----------------------------------------------------
Fax | 866-213-8207
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRENT THOMAS REICHE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 207-571-8028
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CR1313
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------