Provider Demographics
NPI:1851830046
Name:ACTIVE LIFE THERAPIES LLC
Entity type:Organization
Organization Name:ACTIVE LIFE THERAPIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:O
Authorized Official - Last Name:DANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-510-2470
Mailing Address - Street 1:2776 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-2740
Mailing Address - Country:US
Mailing Address - Phone:716-332-0404
Mailing Address - Fax:716-871-1998
Practice Address - Street 1:2776 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2740
Practice Address - Country:US
Practice Address - Phone:716-332-0404
Practice Address - Fax:716-871-1998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)