Provider Demographics
NPI:1770252017
Name:ACTIVE LIFE HEALTH OF LILBURN LLC
Entity Type:Organization
Organization Name:ACTIVE LIFE HEALTH OF LILBURN LLC
Other - Org Name:ARTHRITIS KNEE PAIN CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN & CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-755-1515
Mailing Address - Street 1:629 BEAVER RUIN RD NW STE B
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3437
Mailing Address - Country:US
Mailing Address - Phone:770-755-1515
Mailing Address - Fax:770-370-8173
Practice Address - Street 1:629 BEAVER RUIN RD NW STE B
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3437
Practice Address - Country:US
Practice Address - Phone:770-755-1515
Practice Address - Fax:770-370-8173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty