Provider Demographics
NPI:1558241588
Name:LIVEACTIVE PRIMARY CARE TAMPA, LLC
Entity type:Organization
Organization Name:LIVEACTIVE PRIMARY CARE TAMPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRETHOWR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-549-3884
Mailing Address - Street 1:PO BOX 1269
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-1269
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8849 HAWBUCK ST STE A
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34655-9805
Practice Address - Country:US
Practice Address - Phone:913-549-3884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-02
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care