MEDICARE: ACTIVE SPINE CHIROPRACTIC, P.A.

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	CH10100	FL

General Provider Information

NPI Number	:	1932577160
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE SPINE CHIROPRACTIC, P.A.

Provider Business Mailing Address
First Line	:	2421 NE 65TH ST
Second Line	:	307
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-1556
Country	:	US
Telephone Number	:	786-759-6265
Fax Number	:

Provider Business Practice Location Address
First Line	:	1255 N FLAGLER DR
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-2131
Country	:	US
Telephone Number	:	786-759-6265
Fax Number	:

Authorized Official
Title or Position	:	CEO / OWNER
Name	:	DR. JAY WITTGREEN
Credential	:	D.C.
Telephone Number	:	786-759-6265

Provider Enumeration Date	:	09/03/2015
Last Update Date	:	09/03/2015

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