Basic Information
| Provider Information | |||||||||
| NPI: | 1144777079 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACTIVE MA, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ACTIVE HOME CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 NESHAMINY INTERPLEX | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | TREVOSE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190536964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156426600 | ||||||||
| FaxNumber: | 2156426610 | ||||||||
| Practice Location | |||||||||
| Address1: | 265 BENTON DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | EAST LONGMEADOW | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010283219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135252124 | ||||||||
| FaxNumber: | 4135255691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2016 | ||||||||
| LastUpdateDate: | 09/08/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEHNERT | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 2156426600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ACTIVE DAY, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
No ID Information.