Provider Demographics
NPI:1417767518
Name:ACTIVE HEALTH CLINIC LLC
Entity type:Organization
Organization Name:ACTIVE HEALTH CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KASSRA MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAZALPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MBA
Authorized Official - Phone:415-279-0947
Mailing Address - Street 1:1948 OCEAN RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-2730
Mailing Address - Country:US
Mailing Address - Phone:415-279-0947
Mailing Address - Fax:
Practice Address - Street 1:1948 OCEAN RIDGE CIR
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32963-2730
Practice Address - Country:US
Practice Address - Phone:415-279-0947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-10
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No251F00000XAgenciesHome Infusion
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service