Provider Demographics
NPI:1225330616
Name:ACTIVE LIFE WELLNESS CENTER, INC
Entity Type:Organization
Organization Name:ACTIVE LIFE WELLNESS CENTER, INC
Other - Org Name:ACTIVE PHYSICAL THERAPY & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:323-481-4697
Mailing Address - Street 1:5065 HOLLYWOOD BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6122
Mailing Address - Country:US
Mailing Address - Phone:323-665-7675
Mailing Address - Fax:
Practice Address - Street 1:5065 HOLLYWOOD BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6122
Practice Address - Country:US
Practice Address - Phone:323-481-4697
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-17
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty