1649439969 NPI number — ACTIVE BODY SUPPLIES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649439969 NPI number — ACTIVE BODY SUPPLIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE BODY SUPPLIES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649439969
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18344 CLARK ST
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
TARZANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91356-3505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-704-4754
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18344 CLARK ST
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
TARZANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91356-3505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-704-4754
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PEREZ
Authorized Official First Name:
MARGARET
Authorized Official Middle Name:
E
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
818-704-4754

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  17786DC , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1598771719 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 17786 . This is a "CA CHIROPRACTOR" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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