Provider Demographics
NPI:1366953168
Name:ACTIVE LIFE, LLC
Entity type:Organization
Organization Name:ACTIVE LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:ARDEN
Authorized Official - Last Name:DOTY
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:858-616-7724
Mailing Address - Street 1:1577 E CHEVY CHASE DR STE 210
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4741
Mailing Address - Country:US
Mailing Address - Phone:818-522-8781
Mailing Address - Fax:
Practice Address - Street 1:190 SIERRA CT STE A4
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-7608
Practice Address - Country:US
Practice Address - Phone:818-495-4610
Practice Address - Fax:818-484-2812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-19
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXC0009601Medicaid