Provider Demographics
NPI:1619923349
Name:ACTIVE LIFE ACUPUNCTURE, LLC
Entity Type:Organization
Organization Name:ACTIVE LIFE ACUPUNCTURE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:DONNA
Authorized Official - Last Name:DEMBACK
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:410-337-9293
Mailing Address - Street 1:2300 YORK RD
Mailing Address - Street 2:STE 109
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-2275
Mailing Address - Country:US
Mailing Address - Phone:410-337-9293
Mailing Address - Fax:
Practice Address - Street 1:2300 YORK RD
Practice Address - Street 2:STE 109
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-2275
Practice Address - Country:US
Practice Address - Phone:410-337-9293
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01190171100000X
MDU630171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty