Healthcare Provider Details

I. General information

NPI: 1912368200
Provider Name (Legal Business Name): ACTIVE MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8445 S EASTERN AVE
LAS VEGAS NV
89123-2893
US

IV. Provider business mailing address

8445 S EASTERN AVE
LAS VEGAS NV
89123-2893
US

V. Phone/Fax

Practice location:
  • Phone: 702-463-3784
  • Fax: 702-463-3236
Mailing address:
  • Phone: 702-463-3784
  • Fax: 702-463-3236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberNV20151072257
License Number StateNV

VIII. Authorized Official

Name: SMITA CHAUDHARI
Title or Position: PARTNER
Credential:
Phone: 702-325-3184