Provider Demographics
NPI:1528660206
Name:ACTIVE WELLNESS
Entity type:Organization
Organization Name:ACTIVE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:609-707-2856
Mailing Address - Street 1:6 COVENTRY CT
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-1519
Mailing Address - Country:US
Mailing Address - Phone:609-707-2856
Mailing Address - Fax:
Practice Address - Street 1:6 COVENTRY CT
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-1519
Practice Address - Country:US
Practice Address - Phone:609-707-2856
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy