Provider Demographics
NPI:1083284590
Name:ACTIVE LIFE, LLC
Entity Type:Organization
Organization Name:ACTIVE LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:ARDEN
Authorized Official - Last Name:DOTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-616-7724
Mailing Address - Street 1:1577 E CHEVY CHASE DR STE 210
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4741
Mailing Address - Country:US
Mailing Address - Phone:818-495-4610
Mailing Address - Fax:818-484-2812
Practice Address - Street 1:72780 COUNTRY CLUB DR STE 300
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4150
Practice Address - Country:US
Practice Address - Phone:909-748-0168
Practice Address - Fax:909-748-5881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXC0009601Medicaid