Provider Demographics
NPI:1346819448
Name:ACTIVE LIVING MEDICAL CENTER
Entity type:Organization
Organization Name:ACTIVE LIVING MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:L
Authorized Official - Last Name:JAKIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-384-4904
Mailing Address - Street 1:8257 NARCOOSSEE PARK DR STE 516
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-5545
Mailing Address - Country:US
Mailing Address - Phone:407-616-6279
Mailing Address - Fax:
Practice Address - Street 1:8257 NARCOOSSEE PARK DR STE 516
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-5545
Practice Address - Country:US
Practice Address - Phone:407-384-4904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-22
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty