Healthcare Provider Details

I. General information

NPI: 1922577659
Provider Name (Legal Business Name): ACTIVE LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2804 FORUM BLVD STE 1A
COLUMBIA MO
65203-6322
US

IV. Provider business mailing address

2804 FORUM BLVD STE 1A
COLUMBIA MO
65203-6322
US

V. Phone/Fax

Practice location:
  • Phone: 573-999-7805
  • Fax: 573-446-4949
Mailing address:
  • Phone: 573-999-7805
  • Fax: 573-446-4949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL HENLEY
Title or Position: DOCTOR
Credential: DC
Phone: 573-356-1876