Provider Demographics
NPI:1932616000
Name:TAMPA ACTIVE HEALTH
Entity Type:Organization
Organization Name:TAMPA ACTIVE HEALTH
Other - Org Name:TAMPA ACTIVE HEALTH LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:ST HILAIRE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-955-6742
Mailing Address - Street 1:4015 N. ARMENIA AVE.
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1001
Mailing Address - Country:US
Mailing Address - Phone:813-955-6742
Mailing Address - Fax:833-216-0501
Practice Address - Street 1:4015 N. ARMENIA AVE.
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-1001
Practice Address - Country:US
Practice Address - Phone:813-955-6742
Practice Address - Fax:833-216-0501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381504800Medicaid