Provider Demographics
NPI:1568961977
Name:ACTIVE LIFE, LLC
Entity Type:Organization
Organization Name:ACTIVE LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PALLAVI
Authorized Official - Middle Name:CHINTAPALLI
Authorized Official - Last Name:NEMANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-552-6311
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 1:1135 S SUNSET AVE STE 302
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3964
Practice Address - Country:US
Practice Address - Phone:626-727-6455
Practice Address - Fax:626-360-3220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXC0009601Medicaid