Healthcare Provider Details

I. General information

NPI: 1710444658
Provider Name (Legal Business Name): ACTIVE HEALTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 S WALDRON RD
FORT SMITH AR
72903-3733
US

IV. Provider business mailing address

2220 S WALDRON RD
FORT SMITH AR
72903-3733
US

V. Phone/Fax

Practice location:
  • Phone: 479-659-2342
  • Fax:
Mailing address:
  • Phone: 479-659-2342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: EMILY ROBERTS
Title or Position: PRESIDENT
Credential: OTR/L
Phone: 479-659-2342