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General NPI Number Information
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NPI Number | 1780865311
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Entity Type | Organization
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Legal Business Name | PRO ACTIVE CHIROPRACTIC GROUP INC
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Dates
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Enumeration Date | 11/26/2007
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Last Update Date | 06/08/2020
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Provider Practice Location Address
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Address Line | 4591 E HIGHWAY 20 STE 201
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City | NICEVILLE
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State | FL
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Zip | 32578-8845
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Country | US
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Telephone | 850-279-4913
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Fax | 850-279-4975
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Provider Business Mailing Address
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Address Line | 4591 E HIGHWAY 20 STE 201
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City | NICEVILLE
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State | FL
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Zip | 32578-8845
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Country | US
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Telephone | 850-279-4913
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Fax | 850-279-4975
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Authorized Official
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Title or Position | CEO
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Name | BRIAN SCHUESSLER
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Credential | DC
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Telephone | 850-685-7734
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH 8262
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License Number State | FL
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