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General NPI Number Information
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NPI Number | 1205779089
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Entity Type | Organization
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Legal Business Name | ACTIVE WELLNESS CENTER LLC
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Dates
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Enumeration Date | 04/14/2026
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Last Update Date | 04/14/2026
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Provider Practice Location Address
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Address Line | 593 NW YORK DR
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City | BEND
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State | OR
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Zip | 97703-7264
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Country | US
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Telephone | 541-948-0993
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Fax |
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Provider Business Mailing Address
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Address Line | 20714 SNOW PEAKS DR
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City | BEND
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State | OR
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Zip | 97701-8027
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Country | US
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Telephone | 541-948-0993
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. MARK DAVID DEJOHN
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Credential | LMT
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Telephone | 541-948-0993
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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