Healthcare Provider Details

I. General information

NPI: 1134507908
Provider Name (Legal Business Name): ACTIVE LIFE MEDICAL MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2015
Last Update Date: 05/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 JACKSON ST STE. C-322
ALEXANDRIA LA
71303-2555
US

IV. Provider business mailing address

PO BOX 586
YUBA CITY CA
95992-0586
US

V. Phone/Fax

Practice location:
  • Phone: 318-442-2200
  • Fax: 318-442-2208
Mailing address:
  • Phone: 530-455-5670
  • Fax: 530-455-5669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberDME000481
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License NumberDME000481
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License NumberDME000481
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License NumberDME000481
License Number StateLA

VIII. Authorized Official

Name: JEFFREY SOUZA
Title or Position: PRESIDENT
Credential:
Phone: 318-442-2200