Basic Information
Provider Information | |||||||||
NPI: | 1003957200 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ACTIVE MA, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ACTIVE DAY OF NEW BEDFORD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6 NESHAMINY INTERPLEX DR | ||||||||
Address2: | SUITE 401 | ||||||||
City: | TREVOSE | ||||||||
State: | PA | ||||||||
PostalCode: | 190536964 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2156426600 | ||||||||
FaxNumber: | 2156426610 | ||||||||
Practice Location | |||||||||
Address1: | 107 WELBY RD | ||||||||
Address2: |   | ||||||||
City: | NEW BEDFORD | ||||||||
State: | MA | ||||||||
PostalCode: | 027451135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5089988100 | ||||||||
FaxNumber: | 5089988163 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/09/2007 | ||||||||
LastUpdateDate: | 09/09/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MEHNERT | ||||||||
AuthorizedOfficialFirstName: | CRAIG | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 2156426600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ACTIVE DAY, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X |   | MA | N |   | Respite Care Facility | Respite Care |   | 261QA0600X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
ID | Type | State | Issuer | Description | 1903195 | 05 | MA |   | MEDICAID |