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General NPI Number Information
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NPI Number | 1558241588
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Entity Type | Organization
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Legal Business Name | LIVEACTIVE PRIMARY CARE TAMPA, LLC
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Dates
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Enumeration Date | 09/02/2025
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Last Update Date | 09/02/2025
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Provider Practice Location Address
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Address Line | 8849 HAWBUCK ST STE A
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City | NEW PORT RICHEY
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State | FL
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Zip | 34655-9805
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Country | US
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Telephone | 913-549-3884
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1269
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City | BELLEVUE
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State | NE
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Zip | 68005-1269
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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 | CEO/AUTHORIZED OFFICIAL
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Name | SHANE BRETHOWR
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Credential |
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Telephone | 913-549-3884
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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