1417967944 NPI number — ACTIVE DEVELOPMENT THERAPIES, LLC

Table of Contents

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:
06/24/2024
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:
23435 FM 1314 RD STE C6
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:
77365-7738
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: 261QR0401X ; 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: 173277801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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