=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912714148
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACTIVE RX LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2024
-----------------------------------------------------
Last Update Date | 01/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12700 LOWDEN LN UNIT 4
-----------------------------------------------------
City | MANCHACA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78652-3605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-387-1539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12700 LOWDEN LN UNIT 4
-----------------------------------------------------
City | MANCHACA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78652-3605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-387-1539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | DR. JOHN LONGORIA
-----------------------------------------------------
Credential | PT, DPT, FAAOMPT
-----------------------------------------------------
Telephone | 512-387-1539
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------