MEDICARE: ACTIVE LIFE MEDICAL MANAGEMENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)	DME000481	LA
2	332BN1400X	Nursing Facility Supplies (DME)	DME000481	LA
3	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	DME000481	LA
4	332BX2000X	Oxygen Equipment & Supplies (DME)	DME000481	LA
5	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DME000481	OTHER	LA	LA PHARMACY LICENSE

General Provider Information

NPI Number	:	1134507908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE LIFE MEDICAL MANAGEMENT

Provider Business Mailing Address
First Line	:	PO BOX 586
Second Line	:
City	:	YUBA CITY
State	:	CA
Zip	:	95992-0586
Country	:	US
Telephone Number	:	530-455-5670
Fax Number	:	530-455-5669

Provider Business Practice Location Address
First Line	:	4501 JACKSON ST
Second Line	:	STE. C-322
City	:	ALEXANDRIA
State	:	LA
Zip	:	71303-2555
Country	:	US
Telephone Number	:	318-442-2200
Fax Number	:	318-442-2208

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JEFFREY SOUZA
Credential	:
Telephone Number	:	318-442-2200

Provider Enumeration Date	:	05/13/2015
Last Update Date	:	05/13/2015

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Directions to “ACTIVE LIFE MEDICAL MANAGEMENT ” Practice Location

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