MEDICARE: ACTIVE HEALTH AND WELLNESS CENTER

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	111NX0800X	Orthopedic Chiropractor	51000262A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427179787
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE HEALTH AND WELLNESS CENTER

Provider Business Mailing Address
First Line	:	3027 MISHAWAKA AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46615-2347
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3027 MISHAWAKA AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46615-2347
Country	:	US
Telephone Number	:	574-259-9355
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PHYSICIAN
Name	:	DR. LISA MEYERS
Credential	:
Telephone Number	:	574-259-9355

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	03/31/2010

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Directions to “ACTIVE HEALTH AND WELLNESS CENTER ” Practice Location

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