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General NPI Number Information
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NPI Number | 1912220690
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Entity Type | Organization
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Legal Business Name | ACTIVE LIVING CHIROPRACTIC INC
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Dates
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Enumeration Date | 03/09/2010
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Last Update Date | 04/24/2023
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Provider Practice Location Address
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Address Line | 704 E. ARLINGTON BLVD.
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City | GREENVILLE
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State | NC
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Zip | 27858
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Country | US
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Telephone | 252-756-6111
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Fax | 252-756-6904
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Provider Business Mailing Address
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Address Line | 704 E. ARLINGTON BLVD.
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City | GREENVILLE
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State | NC
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Zip | 27858
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Country | US
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Telephone | 252-756-6111
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Fax | 252-756-6904
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Authorized Official
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Title or Position | BILLING/WIFE
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Name | MRS. TABATHA BULLOCK WIRTH
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Credential |
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Telephone | 252-756-6111
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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 | 4057
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License Number State | NC
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