Provider Demographics
NPI:1083187553
Name:ACTIVE LIFE SPINE & JOINT CLINIC LLC
Entity type:Organization
Organization Name:ACTIVE LIFE SPINE & JOINT CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMANIEGO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:224-425-0548
Mailing Address - Street 1:3600 E STATE ST STE 222
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-1956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3600 E STATE ST STE 222
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-1956
Practice Address - Country:US
Practice Address - Phone:224-425-0548
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty