Healthcare Provider Details

I. General information

NPI: 1679007975
Provider Name (Legal Business Name): ACTIV REHAB AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3773 RICHMOND AVE SUITE 540
HOUSTON TX
77046-3703
US

IV. Provider business mailing address

3773 RICHMOND AVE SUITE 540
HOUSTON TX
77046-3703
US

V. Phone/Fax

Practice location:
  • Phone: 832-263-3210
  • Fax: 844-965-9064
Mailing address:
  • Phone: 832-263-3210
  • Fax: 844-965-9064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number12269
License Number StateTX

VIII. Authorized Official

Name: DR. THOMAS LE
Title or Position: OWNER/CHIROPRACTOR
Credential: D.C.
Phone: 832-263-3210