Provider Demographics
NPI:1851805493
Name:ACTIVE LIFE ACUPUNCTURE & WELLNESS CENTER
Entity Type:Organization
Organization Name:ACTIVE LIFE ACUPUNCTURE & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:HAYDEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNINGSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-358-7690
Mailing Address - Street 1:2592 N GREGG AVE STE 10
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2592 N GREGG AVE STE 10
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5520
Practice Address - Country:US
Practice Address - Phone:479-358-7690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR065171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty