Provider Demographics
NPI:1992408520
Name:ACTIVE MEDICAL GROUP LLC
Entity type:Organization
Organization Name:ACTIVE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:JORDAN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:505-336-7344
Mailing Address - Street 1:4801 N BUTLER AVE STE 8102
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-0818
Mailing Address - Country:US
Mailing Address - Phone:505-370-1201
Mailing Address - Fax:505-461-1779
Practice Address - Street 1:4801 N BUTLER AVE STE 8102
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-0818
Practice Address - Country:US
Practice Address - Phone:505-370-1201
Practice Address - Fax:505-461-1779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-23
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty