Provider Demographics
NPI:1396553616
Name:ACTIVE LIFE WOUND CENTER A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:ACTIVE LIFE WOUND CENTER A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-436-3015
Mailing Address - Street 1:PO BOX 661587
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95866-1587
Mailing Address - Country:US
Mailing Address - Phone:916-436-3015
Mailing Address - Fax:
Practice Address - Street 1:2 SCRIPPS DR STE 202
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-6207
Practice Address - Country:US
Practice Address - Phone:916-436-3015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty