Provider Demographics
NPI:1972151595
Name:ACTIVE WELLNESS LLC
Entity Type:Organization
Organization Name:ACTIVE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-286-5445
Mailing Address - Street 1:2135 NW EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1109
Mailing Address - Country:US
Mailing Address - Phone:541-829-9505
Mailing Address - Fax:
Practice Address - Street 1:120 SW 4TH ST STE 170
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-4896
Practice Address - Country:US
Practice Address - Phone:541-286-5445
Practice Address - Fax:800-527-4735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty