Basic Information
| Provider Information | |||||||||
| NPI: | 1336353499 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACTIVE SC PCA, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ACTIVE NURSING SERVICES OF GREENVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 NESHAMINY INTERPLEX DR | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | TREVOSE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190536927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156426600 | ||||||||
| FaxNumber: | 2156426610 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 MCBETH ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296113548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644672180 | ||||||||
| FaxNumber: | 8644672167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 12/05/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEHNERT | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| 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 |
ID Information
| ID | Type | State | Issuer | Description | EX0626 | 05 | SC | MEDICAID |