Organization
ACTIVE LIFE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PALLAVI CHINTAPALLI NEMANI (COMPLIANCE OFFICER)
(512) 552-6311
Entity
Organization
Contact information
Practice address
7910 FROST ST STE 320, SAN DIEGO, CA 92123
(619) 488-6196
(619) 272-7615
Mailing address
1577 E CHEVY CHASE DR, SUITE 210, GLENDALE, CA 91206-4147
(818) 495-4610
(818) 484-2812
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
XC0009601
MEDI-CAL
CA
05
—
XC0009601
—
CA
Enumeration date
03/03/2011
Last updated
01/24/2023
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