1427265495 NPI number — ACTIVE CARE MEDICAL ASSOCIATES OF FOREST PARK

Table of content: (NPI 1427265495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427265495 NPI number — ACTIVE CARE MEDICAL ASSOCIATES OF FOREST PARK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE CARE MEDICAL ASSOCIATES OF FOREST PARK
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:
1427265495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
#342 5656 JONESBORO ROAD
Provider Second Line Business Mailing Address:
SUITE #111
Provider Business Mailing Address City Name:
LAKE CITY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-366-4124
Provider Business Mailing Address Fax Number:
404-366-0297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1075 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOREST PARK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-366-4124
Provider Business Practice Location Address Fax Number:
404-366-0297
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CRAWFORD
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
DANIELLE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
404-366-4124

Provider Taxonomy Codes

  • Taxonomy code: 2251S0007X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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