Provider Demographics
NPI:1174016331
Name:ACTIVE INTEGRATED MEDICINE LLC
Entity Type:Organization
Organization Name:ACTIVE INTEGRATED MEDICINE LLC
Other - Org Name:ACTIVE INTEGRATED MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEIF
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-458-5216
Mailing Address - Street 1:329 E PLATTE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-3172
Mailing Address - Country:US
Mailing Address - Phone:970-441-1117
Mailing Address - Fax:
Practice Address - Street 1:329 E PLATTE AVE
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-3172
Practice Address - Country:US
Practice Address - Phone:970-441-1117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-12
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1346781846OtherNPI