MEDICARE: ACTIVE CHIROPRACTIC 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	111N00000X	Chiropractor	DC-30203	CA

General Provider Information

NPI Number	:	1588810782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE CHIROPRACTIC AND WELLNESS CENTER

Provider Business Mailing Address
First Line	:	2440 LAS POSAS RD
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93010-3458
Country	:	US
Telephone Number	:	805-384-0101
Fax Number	:	805-384-0220

Provider Business Practice Location Address
First Line	:	2440 LAS POSAS RD
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93010-3458
Country	:	US
Telephone Number	:	805-384-0101
Fax Number	:	805-384-0220

Authorized Official
Title or Position	:	DOCTOR
Name	:	ROMEO ECLAVEA DIMAANO
Credential	:	DC
Telephone Number	:	805-384-0101

Provider Enumeration Date	:	08/07/2008
Last Update Date	:	08/07/2008

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