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General NPI Number Information
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NPI Number | 1134507908
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Entity Type | Organization
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Legal Business Name | ACTIVE LIFE MEDICAL MANAGEMENT
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Dates
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Enumeration Date | 05/13/2015
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Last Update Date | 05/13/2015
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Provider Practice Location Address
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Address Line | 4501 JACKSON ST STE. C-322
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City | ALEXANDRIA
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State | LA
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Zip | 71303-2555
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Country | US
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Telephone | 318-442-2200
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Fax | 318-442-2208
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Provider Business Mailing Address
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Address Line | PO BOX 586
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City | YUBA CITY
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State | CA
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Zip | 95992-0586
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Country | US
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Telephone | 530-455-5670
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Fax | 530-455-5669
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Authorized Official
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Title or Position | PRESIDENT
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Name | JEFFREY SOUZA
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Credential |
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Telephone | 318-442-2200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number | DME000481
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 332BN1400X
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Taxonomy Name | Nursing Facility Supplies (DME)
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License Number | DME000481
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License Number State | LA
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Taxonomy #3
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Taxonomy Code | 332BP3500X
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Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
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License Number | DME000481
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License Number State | LA
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Taxonomy #4
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Taxonomy Code | 332BX2000X
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Taxonomy Name | Oxygen Equipment & Supplies (DME)
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License Number | DME000481
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License Number State | LA
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Taxonomy #5
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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