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General NPI Number Information
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NPI Number | 1871819532
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Entity Type | Organization
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Legal Business Name | ACTIVE LIFE SOLUTIONS, INC.
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Dates
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Enumeration Date | 04/20/2010
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Last Update Date | 04/20/2010
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Provider Practice Location Address
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Address Line | 850 W INDIANTOWN RD SUITE C
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City | JUPITER
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State | FL
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Zip | 33458-7539
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Country | US
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Telephone | 561-386-8311
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Fax | 561-748-8551
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Provider Business Mailing Address
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Address Line | 6671 W INDIANTOWN RD # 50-438
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City | JUPITER
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State | FL
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Zip | 33458-3991
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Country | US
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Telephone | 561-386-8311
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Fax | 561-748-8551
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. PAUL A LAINE
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Credential | RPT
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Telephone | 561-758-8810
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | ME0076092
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License Number State | FL
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