Healthcare Provider Details

I. General information

NPI: 1114544970
Provider Name (Legal Business Name): ACTIVE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2020
Last Update Date: 06/28/2020
Certification Date: 06/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CALIFORNIA ST FL 11
SAN FRANCISCO CA
94108-2727
US

IV. Provider business mailing address

PO BOX 2358
SAN FRANCISCO CA
94126-2358
US

V. Phone/Fax

Practice location:
  • Phone: 415-377-8595
  • Fax:
Mailing address:
  • Phone: 415-377-8595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS CAREY WHITE III
Title or Position: CFO
Credential:
Phone: 415-377-8595