Provider Demographics
NPI:1619434735
Name:ACTIVE BODY ACTIVE LIFE, LLC
Entity Type:Organization
Organization Name:ACTIVE BODY ACTIVE LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TULSI
Authorized Official - Middle Name:N
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:734-730-4715
Mailing Address - Street 1:653 CANTERBURY CT
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-2501
Mailing Address - Country:US
Mailing Address - Phone:734-730-4715
Mailing Address - Fax:
Practice Address - Street 1:600 S DENTON TAP RD STE 134
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-4551
Practice Address - Country:US
Practice Address - Phone:214-210-0715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy