Provider Demographics
NPI:1104398643
Name:ACTIVE LIFE HOME CARE INC
Entity Type:Organization
Organization Name:ACTIVE LIFE HOME CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ARIEL
Authorized Official - Middle Name:VALLADOLID
Authorized Official - Last Name:CABRAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-748-9390
Mailing Address - Street 1:760 W. LOMITA BLVD.
Mailing Address - Street 2:SUITE 79
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710
Mailing Address - Country:US
Mailing Address - Phone:310-748-9390
Mailing Address - Fax:310-847-6141
Practice Address - Street 1:760 W. LOMITA BLVD.
Practice Address - Street 2:SUITE 79
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710
Practice Address - Country:US
Practice Address - Phone:310-748-9390
Practice Address - Fax:310-847-6141
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACTIVE LIFE HOME CARE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care