Provider Demographics
NPI:1528506821
Name:ACTIVE LIFE ORTHOTICS AND PROSTHETICS CORP.
Entity type:Organization
Organization Name:ACTIVE LIFE ORTHOTICS AND PROSTHETICS CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PALLAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:NEMANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-552-6311
Mailing Address - Street 1:124 ALVARADO DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-2940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8380 CERRILLOS RD STE 304
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4418
Practice Address - Country:US
Practice Address - Phone:505-510-7171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-07
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier