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General NPI Number Information
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NPI Number | 1467745190
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Entity Type | Organization
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Legal Business Name | PRO ACTIVE CHIROPRACTIC
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Dates
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Enumeration Date | 05/27/2011
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Last Update Date | 05/27/2011
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Provider Practice Location Address
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Address Line | 340 S GLENDORA AVE SUITE #4
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City | GLENDORA
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State | CA
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Zip | 91741-6255
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Country | US
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Telephone | 626-335-1007
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Fax | 626-335-1002
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Provider Business Mailing Address
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Address Line | 340 S GLENDORA AVE SUITE #4
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City | GLENDORA
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State | CA
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Zip | 91741-6255
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Country | US
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Telephone | 626-335-1007
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Fax | 626-335-1002
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Authorized Official
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Title or Position | OWNER, CHIROPRACTOR
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Name | MR. DAVID LOWELL BOLTON
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Credential | DC
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Telephone | 626-335-1007
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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 | DC29572
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License Number State | CA
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