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General NPI Number Information
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NPI Number | 1083905301
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Entity Type | Organization
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Legal Business Name | ACTIVE LIFESTYLE CHIROPRACTIC
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Dates
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Enumeration Date | 04/20/2011
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Last Update Date | 04/20/2011
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Provider Practice Location Address
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Address Line | 16515 S 40TH ST SUITE 129
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City | PHOENIX
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State | AZ
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Zip | 85048-0558
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Country | US
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Telephone | 480-704-1050
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Fax | 480-704-0109
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Provider Business Mailing Address
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Address Line | 16515 S 40TH ST SUITE 129
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City | PHOENIX
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State | AZ
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Zip | 85048-0558
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Country | US
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Telephone | 480-704-1050
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Fax | 480-704-0109
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Authorized Official
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Title or Position | OWNER
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Name | DR. JENNIFER RENEE WINTON
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Credential | DC
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Telephone | 480-704-1050
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 7750
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License Number State | AZ
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