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General NPI Number Information
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NPI Number | 1972151595
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Entity Type | Organization
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Legal Business Name | ACTIVE WELLNESS LLC
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Dates
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Enumeration Date | 08/27/2019
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Last Update Date | 08/27/2019
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Provider Practice Location Address
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Address Line | 120 SW 4TH ST STE 170
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City | CORVALLIS
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State | OR
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Zip | 97333-4896
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Country | US
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Telephone | 541-286-5445
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Fax | 800-527-4735
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Provider Business Mailing Address
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Address Line | 2135 NW EVERGREEN ST
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City | CORVALLIS
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State | OR
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Zip | 97330-1109
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Country | US
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Telephone | 541-829-9505
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Fax |
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Authorized Official
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Title or Position | OT/OWNER
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Name | PEGGY STEIN
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Credential |
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Telephone | 541-286-5445
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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