MEDICARE: ACTIVE SPINE & SPORT THERAPY PC

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	225100000X	Physical Therapist	6628	AZ
2	111N00000X	Chiropractor	7573	AZ

General Provider Information

NPI Number	:	1518130319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE SPINE & SPORT THERAPY PC

Provider Business Mailing Address
First Line	:	1445 S ARIZONA AVE STE 12
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85286-6509
Country	:	US
Telephone Number	:	480-726-3055
Fax Number	:	480-726-3508

Provider Business Practice Location Address
First Line	:	1445 S ARIZONA AVE STE 12
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85286-6509
Country	:	US
Telephone Number	:	480-726-3305
Fax Number	:	480-726-3508

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JONATHAN JOSEPH DAVID
Credential	:	D.C.
Telephone Number	:	480-726-3305

Provider Enumeration Date	:	04/12/2008
Last Update Date	:	06/01/2023

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