1417967944 NPI number — ACTIVE DEVELOPMENT THERAPIES, LLC

Table of content: (NPI 1417967944)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417967944 NPI number — ACTIVE DEVELOPMENT THERAPIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE DEVELOPMENT THERAPIES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417967944
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77365-0009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-354-3383
Provider Business Mailing Address Fax Number:
281-354-6750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23750 FM 1314 RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77365-3713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-354-3383
Provider Business Practice Location Address Fax Number:
281-354-6750
Provider Enumeration Date:
08/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LOVING
Authorized Official First Name:
KIMBERLYN
Authorized Official Middle Name:
DELANE
Authorized Official Title or Position:
PRESIDENT/ DIRECTOR OF HABILITATION
Authorized Official Telephone Number:
281-354-3383

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 173277803 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 173277801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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