1285775411 NPI number — ACTIVE MA, INC.

Table of content: (NPI 1285775411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285775411 NPI number — ACTIVE MA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE MA, INC.
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:
6
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:
1285775411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 NESHAMINY INTERPLEX DR
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
TREVOSE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19053-6964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-642-6600
Provider Business Mailing Address Fax Number:
215-642-6610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 SCONTICUT NECK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRHAVEN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02719-1914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-990-0607
Provider Business Practice Location Address Fax Number:
508-990-0702
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MEHNERT
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
215-642-6600

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 385H00000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1903209 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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