Provider Demographics
NPI:1922577659
Name:ACTIVE LIFE LLC
Entity Type:Organization
Organization Name:ACTIVE LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HENLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:573-356-1876
Mailing Address - Street 1:2804 FORUM BLVD STE 1A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-6322
Mailing Address - Country:US
Mailing Address - Phone:573-999-7805
Mailing Address - Fax:573-446-4949
Practice Address - Street 1:2804 FORUM BLVD STE 1A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-6322
Practice Address - Country:US
Practice Address - Phone:573-999-7805
Practice Address - Fax:573-446-4949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty