Provider Demographics
NPI:1417513193
Name:ACTIVE LIFE HEALTH OF CINCINNATI LLC
Entity Type:Organization
Organization Name:ACTIVE LIFE HEALTH OF CINCINNATI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-928-1697
Mailing Address - Street 1:PO BOX 79662
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0662
Mailing Address - Country:US
Mailing Address - Phone:513-904-5888
Mailing Address - Fax:513-904-5867
Practice Address - Street 1:8251 PINE RD STE 205
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2191
Practice Address - Country:US
Practice Address - Phone:513-904-5888
Practice Address - Fax:513-904-5867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty