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General NPI Number Information
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NPI Number | 1154378875
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Entity Type | Organization
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Legal Business Name | ACTIVE LIFESTYLES WELLNESS & PERFORMANCE CTR
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Dates
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Enumeration Date | 05/28/2006
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Last Update Date | 02/13/2018
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Provider Practice Location Address
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Address Line | 1715 37TH PL THIRD FLOOR
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City | VERO BEACH
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State | FL
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Zip | 32960-4502
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Country | US
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Telephone | 772-978-7379
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Fax | 772-539-8515
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Provider Business Mailing Address
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Address Line | 1715 37TH PL THIRD FLOOR
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City | VERO BEACH
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State | FL
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Zip | 32960-4502
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Country | US
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Telephone | 772-978-7379
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Fax | 772-539-8515
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Authorized Official
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Title or Position | OWNER
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Name | DR. GIORGIO G RES
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Credential | D.C., P.T.
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Telephone | 772-978-7379
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH9113
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT22446
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License Number State | FL
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