Provider Demographics
NPI:1740883602
Name:ACTIVE RECOVERY TMS LLC
Entity type:Organization
Organization Name:ACTIVE RECOVERY TMS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-708-9901
Mailing Address - Street 1:4949 MEADOWS RD STE 250
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-3147
Mailing Address - Country:US
Mailing Address - Phone:503-708-9901
Mailing Address - Fax:
Practice Address - Street 1:4949 MEADOWS RD STE 250
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3147
Practice Address - Country:US
Practice Address - Phone:503-708-9901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR2084P0800XOtherCOMMERCIAL INSURANCE
OR2084P0800XMedicaid