MEDICARE: ACTIVELIFE REGENERATIVE THERAPIES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1225708886
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVELIFE REGENERATIVE THERAPIES

Provider Business Mailing Address
First Line	:	413 WANAQUE AVE
Second Line	:
City	:	POMPTON LAKES
State	:	NJ
Zip	:	07442-1844
Country	:	US
Telephone Number	:	973-997-0542
Fax Number	:	973-831-6763

Provider Business Practice Location Address
First Line	:	413 WANAQUE AVE
Second Line	:
City	:	POMPTON LAKES
State	:	NJ
Zip	:	07442-1844
Country	:	US
Telephone Number	:	973-997-0542
Fax Number	:	973-831-6763

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KENNETH WOLOSZ
Credential	:	DC
Telephone Number	:	973-997-0542

Provider Enumeration Date	:	09/15/2021
Last Update Date	:	01/05/2022

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