Healthcare Provider Details

I. General information

NPI: 1053774042
Provider Name (Legal Business Name): ACTIVE LIFE AUDIOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8903 GLADES RD STE A14
BOCA RATON FL
33434-4023
US

IV. Provider business mailing address

8903 GLADES RD STE A-14A
BOCA RATON FL
33434-4074
US

V. Phone/Fax

Practice location:
  • Phone: 561-221-0450
  • Fax: 954-827-0591
Mailing address:
  • Phone: 561-221-0450
  • Fax: 561-423-4084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State

VIII. Authorized Official

Name: MICHANNE ALEXIS DAVIDSON
Title or Position: AUDIOLOGIST AND OWNER
Credential: AU.D.
Phone: 561-221-0450