Basic Information
| Provider Information | |||||||||
| NPI: | 1497895627 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACTIVE SC TWO, INC. | ||||||||
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| OtherOrganizationName: | RIDGELAND ACTIVE DAY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 REDLAND CT | ||||||||
| Address2: | SUITE 114 | ||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211173270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4435482200 | ||||||||
| FaxNumber: | 4435482260 | ||||||||
| Practice Location | |||||||||
| Address1: | 8205 E MAIN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | RIDGELAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299368576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437266077 | ||||||||
| FaxNumber: | 8437266074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 05/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | BALDOCK | ||||||||
| AuthorizedOfficialFirstName: | KRIS | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN, CEO, PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4435482201 | ||||||||
| 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 |
ID Information
| ID | Type | State | Issuer | Description | EX0426 | 05 | SC | MEDICAID |