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General NPI Number Information
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NPI Number | 1841098050
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Entity Type | Organization
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Legal Business Name | ACTIVELIFE THERAPY LLC
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Dates
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Enumeration Date | 03/04/2025
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Last Update Date | 03/04/2025
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Provider Practice Location Address
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Address Line | 34121 U.S. 45 GRAYSLAKE, IL 60030, USA STE 10
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City | GAGES LAKE
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State | IL
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Zip | 60030
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Country | US
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Telephone | 224-499-4494
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Fax |
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Provider Business Mailing Address
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Address Line | 809 W GREENWOOD AVE APT 1D
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City | WAUKEGAN
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State | IL
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Zip | 60087-5049
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Country | US
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Telephone | 224-499-4494
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RONALD SAMANIEGO
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Credential | PT
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Telephone | 224-499-4494
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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