Basic Information
| Provider Information | |||||||||
| NPI: | 1447432638 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACTIVE DAY IN, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ACTIVE DAY OF INDIANAPOLIS NORTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7 NESHAMINY INTERPLEX DR | ||||||||
| Address2: | |||||||||
| City: | TREVOSE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190536927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156426600 | ||||||||
| FaxNumber: | 2156426610 | ||||||||
| Practice Location | |||||||||
| Address1: | 9615 N COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462801627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175690014 | ||||||||
| FaxNumber: | 3175691364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2007 | ||||||||
| LastUpdateDate: | 12/08/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEHNERT | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 2156426600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ACTIVE DAY, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | I | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
| ID | Type | State | Issuer | Description | 200882150 A | 05 | IN | MEDICAID |