MEDICARE: MY LIFE ALIVE 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	251S00000X	Community/Behavioral Health Agency	C4060	OR

General Provider Information

NPI Number	:	1699129445
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY LIFE ALIVE LLC

Provider Business Mailing Address
First Line	:	PO BOX 4461
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-8461
Country	:	US
Telephone Number	:	503-807-3444
Fax Number	:

Provider Business Practice Location Address
First Line	:	388 STATE ST
Second Line	:	SUITE 705
City	:	SALEM
State	:	OR
Zip	:	97301-3866
Country	:	US
Telephone Number	:	503-807-3444
Fax Number	:

Authorized Official
Title or Position	:	COUNSELOR
Name	:	CARMEN HEIDECKE
Credential	:
Telephone Number	:	503-807-3444

Provider Enumeration Date	:	04/18/2016
Last Update Date	:	04/18/2016

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Directions to “MY LIFE ALIVE LLC ” Practice Location

Language	Start Address	Practice Location

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