MEDICARE: ACTIVE CHIROPRACTIC CLINIC INC

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	111NS0005X	Sports Physician Chiropractor	08001237	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00006924	OTHER	IN	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	000000344943	OTHER	IN	BCBS

General Provider Information

NPI Number	:	1427233485
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE CHIROPRACTIC CLINIC INC

Provider Business Mailing Address
First Line	:	5845 SUNNYSIDE RD
Second Line	:	SUITE 800
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46235-8402
Country	:	US
Telephone Number	:	317-826-2273
Fax Number	:	317-826-2673

Provider Business Practice Location Address
First Line	:	5845 SUNNYSIDE RD
Second Line	:	SUITE 800
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46235-8402
Country	:	US
Telephone Number	:	317-826-2273
Fax Number	:	317-826-2673

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TIMOTHY J KISTLER
Credential	:	D.C.
Telephone Number	:	317-826-2273

Provider Enumeration Date	:	01/08/2008
Last Update Date	:	02/06/2008

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Directions to “ACTIVE CHIROPRACTIC CLINIC INC ” Practice Location

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