Healthcare Provider Details

I. General information

NPI: 1205779089
Provider Name (Legal Business Name): ACTIVE WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2026
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 NW YORK DR
BEND OR
97703-7264
US

IV. Provider business mailing address

20714 SNOW PEAKS DR
BEND OR
97701-8027
US

V. Phone/Fax

Practice location:
  • Phone: 541-948-0993
  • Fax:
Mailing address:
  • Phone: 541-948-0993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK DAVID DEJOHN
Title or Position: OWNER
Credential: LMT
Phone: 541-948-0993