Provider Demographics
NPI:1366112609
Name:ACTIVE INTEGRATED HEALTH
Entity type:Organization
Organization Name:ACTIVE INTEGRATED HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BELLUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-505-8198
Mailing Address - Street 1:12402 W SOLEDAD ST
Mailing Address - Street 2:
Mailing Address - City:EL MIRAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85335-7244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12402 W SOLEDAD ST
Practice Address - Street 2:
Practice Address - City:EL MIRAGE
Practice Address - State:AZ
Practice Address - Zip Code:85335-7244
Practice Address - Country:US
Practice Address - Phone:623-262-8239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)