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General NPI Number Information
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NPI Number | 1366112609
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Entity Type | Organization
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Legal Business Name | ACTIVE INTEGRATED HEALTH
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Dates
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Enumeration Date | 09/17/2021
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Last Update Date | 09/17/2021
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Provider Practice Location Address
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Address Line | 12402 W SOLEDAD ST
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City | EL MIRAGE
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State | AZ
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Zip | 85335-7244
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Country | US
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Telephone | 623-262-8239
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Fax |
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Provider Business Mailing Address
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Address Line | 12402 W SOLEDAD ST
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City | EL MIRAGE
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State | AZ
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Zip | 85335-7244
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PART OWNER
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Name | MR. BRYCE BELLUE
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Credential |
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Telephone | 623-505-8198
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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