Provider Demographics
NPI:1275891756
Name:ARIZONA ACTIVE AGING, LLC
Entity Type:Organization
Organization Name:ARIZONA ACTIVE AGING, LLC
Other - Org Name:ACTIVE RX - SUN LAKES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:WEIDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-361-2217
Mailing Address - Street 1:10440 E RIGGS RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SUN LAKES
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-7751
Mailing Address - Country:US
Mailing Address - Phone:480-361-2217
Mailing Address - Fax:480-664-4223
Practice Address - Street 1:10440 E RIGGS RD
Practice Address - Street 2:SUITE 120
Practice Address - City:SUN LAKES
Practice Address - State:AZ
Practice Address - Zip Code:85248-7751
Practice Address - Country:US
Practice Address - Phone:480-361-2217
Practice Address - Fax:480-664-4223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy