Healthcare Provider Details

I. General information

NPI: 1437592417
Provider Name (Legal Business Name): ACTIVEHEALTHRX, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 04/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 WILSHIRE BLVD PH
BEVERLY HILLS CA
90211-3121
US

IV. Provider business mailing address

8500 WILSHIRE BLVD PH
BEVERLY HILLS CA
90211-3121
US

V. Phone/Fax

Practice location:
  • Phone: 310-652-0085
  • Fax: 866-390-0007
Mailing address:
  • Phone: 310-652-0085
  • Fax: 866-390-0007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberCPT54625
License Number StateCA

VIII. Authorized Official

Name: IAN LICHTWARDT
Title or Position: DIRECTOR
Credential:
Phone: 310-741-7799