Provider Demographics
NPI:1942767975
Name:ACTIVE LIFE PROJECT
Entity Type:Organization
Organization Name:ACTIVE LIFE PROJECT
Other - Org Name:ACTIVE LIFE PROJECT LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:M
Authorized Official - Last Name:VELEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:919-225-2065
Mailing Address - Street 1:40 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:HADDON TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-2314
Mailing Address - Country:US
Mailing Address - Phone:856-477-9330
Mailing Address - Fax:
Practice Address - Street 1:987 HADDON AVE
Practice Address - Street 2:
Practice Address - City:COLLINGSWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08108-2048
Practice Address - Country:US
Practice Address - Phone:856-607-2115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty