Healthcare Provider Details

I. General information

NPI: 1891520631
Provider Name (Legal Business Name): ACTIVE LIFE MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 09/03/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 W MOANA LN
RENO NV
89509-4844
US

IV. Provider business mailing address

971 W MOANA LN
RENO NV
89509-4844
US

V. Phone/Fax

Practice location:
  • Phone: 775-842-0065
  • Fax:
Mailing address:
  • Phone: 775-842-0065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: EDITH BEREJNAYA
Title or Position: CO-OWNER
Credential: FNP
Phone: 775-848-6085