Provider Demographics
NPI:1053883850
Name:ACTIVE RECOVERY LLC
Entity type:Organization
Organization Name:ACTIVE RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:AUGUST
Authorized Official - Last Name:WORREL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPT
Authorized Official - Phone:601-297-1740
Mailing Address - Street 1:500 MAMIE ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-5042
Mailing Address - Country:US
Mailing Address - Phone:601-297-1740
Mailing Address - Fax:
Practice Address - Street 1:3906 HARDY ST # 15
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1683
Practice Address - Country:US
Practice Address - Phone:601-297-1740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-19
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1528307469OtherNPI