Provider Demographics
NPI:1437649183
Name:ACTIVE FOR LIFE LLC
Entity Type:Organization
Organization Name:ACTIVE FOR LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:908-303-5846
Mailing Address - Street 1:20 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-1628
Mailing Address - Country:US
Mailing Address - Phone:908-303-5846
Mailing Address - Fax:
Practice Address - Street 1:20 W SPRING ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-1628
Practice Address - Country:US
Practice Address - Phone:908-303-5846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA012553002251P0200X
NJ46TR00658900225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty