Healthcare Provider Details

I. General information

NPI: 1295256980
Provider Name (Legal Business Name): ACTIVE MA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 07/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 WELBY RD
NEW BEDFORD MA
02745-1118
US

IV. Provider business mailing address

6 NESHAMINY INTERPLEX DR STE 401
TREVOSE PA
19053-6942
US

V. Phone/Fax

Practice location:
  • Phone: 508-985-9076
  • Fax: 508-985-6026
Mailing address:
  • Phone: 215-642-6600
  • Fax: 215-642-6610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CRAIG O MEHNERT
Title or Position: COO
Credential:
Phone: 215-642-6600