Provider Demographics
NPI:1477981066
Name:ACTIVECARERX WELLNESS, LLC
Entity Type:Organization
Organization Name:ACTIVECARERX WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:IDRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-757-4651
Mailing Address - Street 1:1301 DOVE ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2412
Mailing Address - Country:US
Mailing Address - Phone:949-757-0571
Mailing Address - Fax:949-757-1056
Practice Address - Street 1:1301 DOVE ST
Practice Address - Street 2:SUITE 800
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2412
Practice Address - Country:US
Practice Address - Phone:949-757-0571
Practice Address - Fax:949-757-1056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-17
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center