Provider Demographics
NPI:1811640881
Name:ACTIVE ASSISTED LIVING LLC
Entity type:Organization
Organization Name:ACTIVE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLAUDIA
Authorized Official - Middle Name:P
Authorized Official - Last Name:ALUR
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:813-530-4270
Mailing Address - Street 1:226 CLAYTON ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5201
Mailing Address - Country:US
Mailing Address - Phone:813-530-4270
Mailing Address - Fax:813-530-4271
Practice Address - Street 1:226 CLAYTON ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5201
Practice Address - Country:US
Practice Address - Phone:813-530-4270
Practice Address - Fax:813-530-4271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-31
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility