=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427233485
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACTIVE CHIROPRACTIC CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2008
-----------------------------------------------------
Last Update Date | 02/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5845 SUNNYSIDE RD SUITE 800
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46235-8402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-826-2273
-----------------------------------------------------
Fax | 317-826-2673
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5845 SUNNYSIDE RD SUITE 800
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46235-8402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-826-2273
-----------------------------------------------------
Fax | 317-826-2673
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TIMOTHY J KISTLER
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 317-826-2273
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 08001237
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------