Provider Demographics
NPI:1134507908
Name:ACTIVE LIFE MEDICAL MANAGEMENT
Entity Type:Organization
Organization Name:ACTIVE LIFE MEDICAL MANAGEMENT
Other - Org Name:ACTIVE LIFE MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-442-2200
Mailing Address - Street 1:PO BOX 586
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95992-0586
Mailing Address - Country:US
Mailing Address - Phone:530-455-5670
Mailing Address - Fax:530-455-5669
Practice Address - Street 1:4501 JACKSON ST
Practice Address - Street 2:STE. C-322
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2555
Practice Address - Country:US
Practice Address - Phone:318-442-2200
Practice Address - Fax:318-442-2208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
LADME000481332BC3200X, 332BN1400X, 332BP3500X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LADME000481OtherLA PHARMACY LICENSE