Provider Demographics
NPI:1578841482
Name:ACTIVE HEALTH & WELLNESS CENTER, INC.
Entity Type:Organization
Organization Name:ACTIVE HEALTH & WELLNESS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:U
Authorized Official - Last Name:BRECHER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-933-5259
Mailing Address - Street 1:4015 N ARMENIA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1001
Mailing Address - Country:US
Mailing Address - Phone:813-933-5259
Mailing Address - Fax:813-935-3698
Practice Address - Street 1:4015 N ARMENIA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-1001
Practice Address - Country:US
Practice Address - Phone:813-933-5259
Practice Address - Fax:813-935-3698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-26
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0007261111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55553ZMedicare PIN
FLU79470Medicare UPIN