Healthcare Provider Details

I. General information

NPI: 1508648163
Provider Name (Legal Business Name): ACTIVE CHANGE RECOVERY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 01/13/2026
Certification Date: 01/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 E WEBER AVE STE 103
STOCKTON CA
95202-2751
US

IV. Provider business mailing address

1738 BARTLETT CT
STOCKTON CA
95206-6358
US

V. Phone/Fax

Practice location:
  • Phone: 209-921-0971
  • Fax:
Mailing address:
  • Phone: 559-250-1121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. MARTIN SISNEROZ JR.
Title or Position: CEO
Credential:
Phone: 559-250-1121