Provider Demographics
NPI:1053774042
Name:ACTIVE LIFE AUDIOLOGY INC
Entity type:Organization
Organization Name:ACTIVE LIFE AUDIOLOGY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHANNE
Authorized Official - Middle Name:ALEXIS
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:561-221-0450
Mailing Address - Street 1:8903 GLADES RD STE A-14A
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-4074
Mailing Address - Country:US
Mailing Address - Phone:561-221-0450
Mailing Address - Fax:561-423-4084
Practice Address - Street 1:8903 GLADES RD STE A14
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-4023
Practice Address - Country:US
Practice Address - Phone:561-221-0450
Practice Address - Fax:954-827-0591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023122400Medicaid