MEDICARE: ACTIVE LIFE CHIROPRACTIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1053567933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE LIFE CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	2518 E KENOSHA ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74014-6712
Country	:	US
Telephone Number	:	918-286-2729
Fax Number	:

Provider Business Practice Location Address
First Line	:	2518 E KENOSHA ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74014-6712
Country	:	US
Telephone Number	:	918-286-2729
Fax Number	:

Authorized Official
Title or Position	:	ADMIN
Name	:	SALLY MESSINGER
Credential	:
Telephone Number	:	918-286-2729

Provider Enumeration Date	:	08/12/2008
Last Update Date	:	10/08/2008

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