=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811130016
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACTIVE LIFE PHYSICAL MEDICINE AND PAIN CENTER, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2009
-----------------------------------------------------
Last Update Date | 05/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15547 N REEMS RD BLDG A
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85374-9583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-535-9777
-----------------------------------------------------
Fax | 623-535-9778
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15547 N REEMS RD BLDG A
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85374-9583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-535-9777
-----------------------------------------------------
Fax | 623-535-9778
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | DR. WENDI LUNDQUIST
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 623-535-9777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 005097
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------