1215840806 NPI number — ACTIVE HEALTH MEDICAL CENTER, LLC

Table of content: (NPI 1215840806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215840806 NPI number — ACTIVE HEALTH MEDICAL CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE HEALTH MEDICAL CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215840806
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1913 S MINTLE ST TRLR 42
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AIRWAY HEIGHTS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99001-5262
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
870-888-0627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12144 US HIGHWAY 301 N UNIT 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARRISH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34219-1134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
332-286-5417
Provider Business Practice Location Address Fax Number:
870-888-0627
Provider Enumeration Date:
09/24/2026

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDBERG
Authorized Official First Name:
TRACY R.
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
332-286-5417

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of NULL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , registered in the state of NULL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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