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General NPI Number Information
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NPI Number | 1386003259
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Entity Type | Organization
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Legal Business Name | ACTIVE HEALTH PHYSICAL MEDICINE, PLLC
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Dates
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Enumeration Date | 02/19/2016
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Last Update Date | 02/19/2016
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Provider Practice Location Address
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Address Line | 6431 SOUTHWEST BLVD
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City | BENBROOK
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State | TX
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Zip | 76132-2777
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Country | US
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Telephone | 817-738-9777
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Fax |
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Provider Business Mailing Address
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Address Line | 6431 SOUTHWEST BLVD
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City | BENBROOK
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State | TX
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Zip | 76132-2777
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Country | US
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Telephone | 817-738-9777
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Fax |
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Authorized Official
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Title or Position | SOLE MBR
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Name | DR. ELIAS LARA
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Credential | DO
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Telephone | 817-738-9777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State | TX
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