Healthcare Provider Details

I. General information

NPI: 1437649183
Provider Name (Legal Business Name): ACTIVE FOR LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W SPRING ST
SOMERVILLE NJ
08876-1628
US

IV. Provider business mailing address

20 W SPRING ST
SOMERVILLE NJ
08876-1628
US

V. Phone/Fax

Practice location:
  • Phone: 908-303-5846
  • Fax:
Mailing address:
  • Phone: 908-303-5846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number40QA01255300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number46TR00658900
License Number StateNJ

VIII. Authorized Official

Name: DR. KERRI O'CONNOR
Title or Position: DOCTOR
Credential: DPT
Phone: 908-303-5846