Provider Demographics
NPI:1639392798
Name:ACTIVE LIFE MEDICAL CENTER
Entity Type:Organization
Organization Name:ACTIVE LIFE MEDICAL CENTER
Other - Org Name:PHYSICIANS PLUS MEDICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:650-365-7775
Mailing Address - Street 1:1391 WOODSIDE RD
Mailing Address - Street 2:200
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94061-3578
Mailing Address - Country:US
Mailing Address - Phone:650-365-7775
Mailing Address - Fax:365-365-7896
Practice Address - Street 1:1391 WOODSIDE RD
Practice Address - Street 2:200
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94061-3578
Practice Address - Country:US
Practice Address - Phone:650-365-7775
Practice Address - Fax:365-365-7896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14813111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA14813OtherLICENSE
CAA69755OtherLICENSE