MEDICARE: ACTIVE LIFE ADHC LLC

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	261QA0600X	Adult Day Care Clinic/Center

General Provider Information

NPI Number	:	1225810807
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE LIFE ADHC LLC

Provider Business Mailing Address
First Line	:	102 BOOKSTORE WAY
Second Line	:
City	:	BOWLING GREEN
State	:	KY
Zip	:	42101-2810
Country	:	US
Telephone Number	:	502-835-9419
Fax Number	:

Provider Business Practice Location Address
First Line	:	102 BOOKSTORE WAY
Second Line	:
City	:	BOWLING GREEN
State	:	KY
Zip	:	42101-2810
Country	:	US
Telephone Number	:	502-835-9419
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	VITA COKER
Credential	:
Telephone Number	:	502-835-9419

Provider Enumeration Date	:	10/18/2023
Last Update Date	:	10/18/2023

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