Provider Demographics
NPI:1689942294
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
Mailing Address - Street 2:SUITE 210
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4147
Mailing Address - Country:US
Mailing Address - Phone:818-495-4610
Mailing Address - Fax:818-484-2812
Practice Address - Street 1:2140 W CHAPMAN AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2331
Practice Address - Country:US
Practice Address - Phone:714-602-6436
Practice Address - Fax:714-468-5148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
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
CAXC0009601OtherMEDI CAL
CAXC0009601OtherMEDI CAL