Provider Demographics
NPI:1811130016
Name:ACTIVE LIFE PHYSICAL MEDICINE AND PAIN CENTER, PLLC
Entity type:Organization
Organization Name:ACTIVE LIFE PHYSICAL MEDICINE AND PAIN CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDI
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:623-535-9777
Mailing Address - Street 1:15547 N REEMS RD BLDG A
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-9583
Mailing Address - Country:US
Mailing Address - Phone:623-535-9777
Mailing Address - Fax:623-535-9778
Practice Address - Street 1:15547 N REEMS RD BLDG A
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-9583
Practice Address - Country:US
Practice Address - Phone:623-535-9777
Practice Address - Fax:623-535-9778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-17
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0050972081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty