Basic Information
| Provider Information | |||||||||
| NPI: | 1295256980 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACTIVE MA, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ACTIVE DAY OF NEW BEDFORD - CAPEWAY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 NESHAMINY INTERPLEX DR STE 401 | ||||||||
| Address2: | |||||||||
| City: | TREVOSE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190536942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156426600 | ||||||||
| FaxNumber: | 2156426610 | ||||||||
| Practice Location | |||||||||
| Address1: | 81 WELBY RD | ||||||||
| Address2: | |||||||||
| City: | NEW BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027451118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089859076 | ||||||||
| FaxNumber: | 5089856026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2017 | ||||||||
| LastUpdateDate: | 07/03/2017 | ||||||||
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| 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 | 261QA0600X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
No ID Information.