=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215234042
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACTIVE LIFE CHIROPRACTIC & WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2011
-----------------------------------------------------
Last Update Date | 02/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 921 LONGTOWN RD STE. F
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29229-9498
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-699-0266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 921 LONGTOWN RD STE. F
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29229-9498
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-699-0266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR/OWNER
-----------------------------------------------------
Name | EMILY LOUISE DREW
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 803-699-0266
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3537
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------