NPIMap

Organization Active NPI

Active Life Wound Center a Professional Medical Corporation

  • Family Medicine Physician
  • Sacramento, CA
National Provider Identifier
1396553616
Registry record updated Dec 19, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
ACTIVE LIFE WOUND CENTER A PROFESSIONAL MEDICAL CORPORATION
Practice address
2 Scripps Dr Ste 202
Sacramento, CA 95825-6207
Phone
(916) 436-3015
NPI assigned
Dec 19, 2024
Last updated
Dec 19, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 19, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jeffrey SouzaNPI 1831558196
Title
Compliance Manager
Phone
(916) 436-3015

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X NU
Nurse Practitioner 363L00000X NU
Wound Care Registered Nurse 163WW0000X NU
Dermatology Physician 207N00000X NU
Family Medicine Physician 207Q00000X NU Primary

Addresses

Primary practice location

2 Scripps Dr Ste 202
Sacramento, CA 95825-6207

Mailing address

PO Box 661587
Sacramento, CA 95866-1587
Phone (916) 436-3015

Other names 1

  • Active Life Wound Center Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20250602002335 CA Part B Supplier - Clinic/Group Practice 5991214918 Receives reassigned benefits from 7 practitioners
Practice locations: Sacramento, CA

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 21

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 21

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1734566400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1734566400000",
    "number": "1396553616",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 661587",
            "city": "SACRAMENTO",
            "state": "CA",
            "postal_code": "958661587",
            "telephone_number": "916-436-3015"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2 SCRIPPS DR STE 202",
            "city": "SACRAMENTO",
            "state": "CA",
            "postal_code": "958256207",
            "telephone_number": "916-436-3015"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ACTIVE LIFE WOUND CENTER A PROFESSIONAL MEDICAL CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-12-19",
        "last_updated": "2024-12-19",
        "certification_date": "2024-12-19",
        "status": "A",
        "authorized_official_last_name": "SOUZA",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_title_or_position": "COMPLIANCE MANAGER",
        "authorized_official_telephone_number": "916-436-3015"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "163WW0000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse, Wound Care",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Active Life Wound Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Sacramento, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 19, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.