Healthcare Provider Details

I. General information

NPI: 1568301380
Provider Name (Legal Business Name): ACTIVE LIFE HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2102 SAINT GEORGES WAY
BOWIE MD
20721-2296
US

IV. Provider business mailing address

2102 SAINT GEORGES WAY
BOWIE MD
20721-2296
US

V. Phone/Fax

Practice location:
  • Phone: 240-505-9350
  • Fax:
Mailing address:
  • Phone: 240-505-9350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: UKACHI ESEN
Title or Position: OWNER
Credential:
Phone: 240-505-9350