MEDICARE: ACTIVE WELLNESS CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1205779089
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	20714 SNOW PEAKS DR
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97701-8027
Country	:	US
Telephone Number	:	541-948-0993
Fax Number	:

Provider Business Practice Location Address
First Line	:	593 NW YORK DR
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97703-7264
Country	:	US
Telephone Number	:	541-948-0993
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MARK DAVID DEJOHN
Credential	:	LMT
Telephone Number	:	541-948-0993

Provider Enumeration Date	:	04/14/2026
Last Update Date	:	04/14/2026

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Directions to “ACTIVE WELLNESS CENTER LLC ” Practice Location

Language	Start Address	Practice Location

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