=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336328616
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACTIVE CARE WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2007
-----------------------------------------------------
Last Update Date | 01/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 MAIN ST
-----------------------------------------------------
City | STEVENSVILLE
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59870-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-777-1048
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 MAIN ST
-----------------------------------------------------
City | STEVENSVILLE
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59870-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-777-1048
-----------------------------------------------------
Fax | 406-777-1038
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | RENEE CHRISTENSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-777-1048
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1154
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------