Provider Demographics
NPI:1922751163
Name:ACTIVELIFE FITNESS LLC ZOO HEALTH CLUB
Entity Type:Organization
Organization Name:ACTIVELIFE FITNESS LLC ZOO HEALTH CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMANIEGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-368-7133
Mailing Address - Street 1:2513 N POWELL PKWY
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:TX
Mailing Address - Zip Code:75409-2632
Mailing Address - Country:US
Mailing Address - Phone:224-368-7133
Mailing Address - Fax:
Practice Address - Street 1:2513 N POWELL PKWY
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:TX
Practice Address - Zip Code:75409-2632
Practice Address - Country:US
Practice Address - Phone:224-368-7133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty