Healthcare Provider Details

I. General information

NPI: 1003957200
Provider Name (Legal Business Name): ACTIVE MA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 WELBY RD
NEW BEDFORD MA
02745-1135
US

IV. Provider business mailing address

6 NESHAMINY INTERPLEX DR SUITE 401
TREVOSE PA
19053-6964
US

V. Phone/Fax

Practice location:
  • Phone: 508-998-8100
  • Fax: 508-998-8163
Mailing address:
  • Phone: 215-642-6600
  • Fax: 215-642-6610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

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