# ACTIVE LIFE SPINE & JOINT CLINIC LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1083187553
- **Authorized official:** RONALD SAMANIEGO PT (OWNER)
- **Authorized official phone:** (224) 425-0548

## Contact information

- **Practice address:** 3600 E STATE ST STE 222, ROCKFORD, IL 61108-1956
- **Practice address phone:** (224) 425-0548
- **Mailing address:** 3600 E STATE ST STE 222, ROCKFORD, IL 61108-1956

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 225100000X | Physical Therapist | — | NULL | Yes |
| 225100000X | Physical Therapist | — | — | Yes |

## Other

- **Enumeration date:** 01/08/2019
- **Last updated:** 01/08/2019