Provider Demographics
NPI:1154378875
Name:ACTIVE LIFESTYLES WELLNESS & PERFORMANCE CTR
Entity type:Organization
Organization Name:ACTIVE LIFESTYLES WELLNESS & PERFORMANCE CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GIORGIO
Authorized Official - Middle Name:G
Authorized Official - Last Name:RES
Authorized Official - Suffix:
Authorized Official - Credentials:DC, PT
Authorized Official - Phone:772-978-7379
Mailing Address - Street 1:1715 37TH PL
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4502
Mailing Address - Country:US
Mailing Address - Phone:772-978-7379
Mailing Address - Fax:772-539-8515
Practice Address - Street 1:1715 37TH PL
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4502
Practice Address - Country:US
Practice Address - Phone:772-978-7379
Practice Address - Fax:772-539-8515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9113111N00000X, 111N00000X
FLPT22446225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL60994OtherBCBS- DR. RES
FL77915OtherBCBS GROUP #
FL60994OtherBCBS- DR. RES
FLK9908Medicare ID - Type UnspecifiedMEDICARE GROUP #
FLV09417Medicare UPIN
FL60992ZMedicare ID - Type UnspecifiedDR. BEUTTELL
FL60992OtherBCBS-DR. BEUTTELL
FL60994ZMedicare ID - Type UnspecifiedDR. RES
FL5755970001Medicare NSC
FLU8035ZMedicare PIN