Provider Demographics
NPI:1598951329
Name:ACTIVE LIFE HEALTH CENTER L.L.C
Entity Type:Organization
Organization Name:ACTIVE LIFE HEALTH CENTER L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDD
Authorized Official - Middle Name:
Authorized Official - Last Name:WEINBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-522-9800
Mailing Address - Street 1:1155 HAMMOND DR NE
Mailing Address - Street 2:SUITE D 4285
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5320
Mailing Address - Country:US
Mailing Address - Phone:770-522-9800
Mailing Address - Fax:770-522-9878
Practice Address - Street 1:1155 HAMMOND DR NE
Practice Address - Street 2:SUITE D 4285
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5320
Practice Address - Country:US
Practice Address - Phone:770-522-9800
Practice Address - Fax:770-522-9878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIROO7525261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G700731Medicare PIN