Healthcare Provider Details

I. General information

NPI: 1508226440
Provider Name (Legal Business Name): ACTIVE LIFE ADULT DAY CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 03/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7209 TAM O'SHANTER DR.
STOCKTON CA
95210
US

IV. Provider business mailing address

7209 TAM O'SHANTER DR UNIT D
STOCKTON CA
95210-3370
US

V. Phone/Fax

Practice location:
  • Phone: 626-643-6003
  • Fax: 209-267-4193
Mailing address:
  • Phone: 626-643-6003
  • Fax: 209-267-4193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ARA KARAMANOUKIAN
Title or Position: PRESIDENT
Credential:
Phone: 626-643-6003