Provider Demographics
NPI:1679080394
Name:ACTIVE CARE EDMOND PLLC
Entity type:Organization
Organization Name:ACTIVE CARE EDMOND PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-315-4119
Mailing Address - Street 1:3201 E MEMORIAL RD STE B
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-7093
Mailing Address - Country:US
Mailing Address - Phone:405-478-1507
Mailing Address - Fax:405-478-1592
Practice Address - Street 1:3201 E MEMORIAL RD STE B
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-7093
Practice Address - Country:US
Practice Address - Phone:405-478-1507
Practice Address - Fax:405-478-1592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1699833244OtherNPI