Healthcare Provider Details

I. General information

NPI: 1972151595
Provider Name (Legal Business Name): ACTIVE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SW 4TH ST STE 170
CORVALLIS OR
97333-4896
US

IV. Provider business mailing address

2135 NW EVERGREEN ST
CORVALLIS OR
97330-1109
US

V. Phone/Fax

Practice location:
  • Phone: 541-286-5445
  • Fax: 800-527-4735
Mailing address:
  • Phone: 541-829-9505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: PEGGY STEIN
Title or Position: OT/OWNER
Credential:
Phone: 541-286-5445