Provider Demographics
NPI:1871819532
Name:ACTIVE LIFE SOLUTIONS, INC.
Entity Type:Organization
Organization Name:ACTIVE LIFE SOLUTIONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAINE
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:561-758-8810
Mailing Address - Street 1:6671 W INDIANTOWN RD
Mailing Address - Street 2:# 50-438
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-3991
Mailing Address - Country:US
Mailing Address - Phone:561-386-8311
Mailing Address - Fax:561-748-8551
Practice Address - Street 1:850 W INDIANTOWN RD
Practice Address - Street 2:SUITE C
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7539
Practice Address - Country:US
Practice Address - Phone:561-386-8311
Practice Address - Fax:561-748-8551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0076092261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service