Provider Demographics
NPI:1962415661
Name:ACTIVE LIFE MEDICAL MANAGEMENT
Entity type:Organization
Organization Name:ACTIVE LIFE MEDICAL MANAGEMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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:888-525-0255
Mailing Address - Street 1:PO BOX 586
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95992-0586
Mailing Address - Country:US
Mailing Address - Phone:888-525-0255
Mailing Address - Fax:888-525-0255
Practice Address - Street 1:1018 LIVE OAK BLVD., SUITE K
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991
Practice Address - Country:US
Practice Address - Phone:888-525-0255
Practice Address - Fax:888-525-0255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201003378332B00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1526243OtherUMWA
VA262513OtherBCBS
VA1962415661Medicaid