MEDICARE: LIVEACTIVE PRIMARY CARE TAMPA, 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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1558241588
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVEACTIVE PRIMARY CARE TAMPA, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1269
Second Line	:
City	:	BELLEVUE
State	:	NE
Zip	:	68005-1269
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8849 HAWBUCK ST STE A
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34655-9805
Country	:	US
Telephone Number	:	913-549-3884
Fax Number	:

Authorized Official
Title or Position	:	CEO/AUTHORIZED OFFICIAL
Name	:	SHANE BRETHOWR
Credential	:
Telephone Number	:	913-549-3884

Provider Enumeration Date	:	09/02/2025
Last Update Date	:	09/02/2025

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