Healthcare Provider Details

I. General information

NPI: 1326955600
Provider Name (Legal Business Name): ACTIVE GLORY HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 10TH ST S
FARGO ND
58103-3101
US

IV. Provider business mailing address

901 10TH ST S
FARGO ND
58103-3101
US

V. Phone/Fax

Practice location:
  • Phone: 386-315-1170
  • Fax:
Mailing address:
  • Phone: 386-315-1170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MISS JANET JENEBA MASON
Title or Position: CEO/FOUNDER
Credential: CNA
Phone: 386-315-1170