Provider Demographics
NPI:1467593541
Name:ACTIVE LIFESTYLE HEALTHCARE, INC.
Entity Type:Organization
Organization Name:ACTIVE LIFESTYLE HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:CASINO
Authorized Official - Last Name:LESACA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:661-803-7384
Mailing Address - Street 1:21957 MIKHAIL ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91390-5720
Mailing Address - Country:US
Mailing Address - Phone:661-803-7384
Mailing Address - Fax:661-263-6463
Practice Address - Street 1:21957 MIKHAIL ST
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91390-5720
Practice Address - Country:US
Practice Address - Phone:661-803-7384
Practice Address - Fax:661-263-6463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28266225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18132Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER