1720500010 NPI number — ACTIVEKIDZ AND ADULT THERAPY SERVICES

Table of content: (NPI 1720500010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720500010 NPI number — ACTIVEKIDZ AND ADULT THERAPY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVEKIDZ AND ADULT THERAPY SERVICES
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:
1720500010
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1045 OLD MILL TRCE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30656-4379
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-338-8058
Provider Business Mailing Address Fax Number:
678-374-4855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1247 TUSCANY DRIVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BRASELTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30517-3402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-207-6390
Provider Business Practice Location Address Fax Number:
678-374-4855
Provider Enumeration Date:
07/09/2017

Additional Information

Authorized Official

Authorized Official Last Name:
COOK
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-207-6390

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ========= . This is a "TAX ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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