Provider Demographics
NPI:1013970334
Name:ACTIVE LIFESTYLE MEDICAL PC
Entity Type:Organization
Organization Name:ACTIVE LIFESTYLE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SENIOR CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:TINLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-860-0300
Mailing Address - Street 1:9449 N 90TH ST
Mailing Address - Street 2:STE 114
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5099
Mailing Address - Country:US
Mailing Address - Phone:480-860-0300
Mailing Address - Fax:480-422-4321
Practice Address - Street 1:9449 N 90TH ST
Practice Address - Street 2:STE 114
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5099
Practice Address - Country:US
Practice Address - Phone:480-860-0300
Practice Address - Fax:480-422-4321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-08
Last Update Date:2015-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ000000000928481261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ6476010001Medicare PIN
AZZ103004Medicare PIN