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General NPI Number Information
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NPI Number | 1194149203
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Entity Type | Organization
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Legal Business Name | ACTIVE CHIROPRACTIC P C
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Dates
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Enumeration Date | 02/10/2014
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Last Update Date | 02/10/2014
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Provider Practice Location Address
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Address Line | 1001 13TH AVE N
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City | CLINTON
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State | IA
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Zip | 52732-3403
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Country | US
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Telephone | 563-242-9343
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Fax |
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Provider Business Mailing Address
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Address Line | 1001 13TH AVE N
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City | CLINTON
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State | IA
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Zip | 52732-3403
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Country | US
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Telephone | 563-242-9343
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRIAN R DORNBUSH
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Credential | D.C.
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Telephone | 563-242-9343
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | A06166
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License Number State | IA
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