Healthcare Provider Details

I. General information

NPI: 1215840806
Provider Name (Legal Business Name): ACTIVE HEALTH MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12144 US HIGHWAY 301 N UNIT 101
PARRISH FL
34219-1134
US

IV. Provider business mailing address

PO BOX 682
AIRWAY HEIGHTS WA
99001-0682
US

V. Phone/Fax

Practice location:
  • Phone: 332-286-5417
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: TRACY R. GOLDBERG
Title or Position: DIRECTOR
Credential:
Phone: 332-286-5417