Healthcare Provider Details

I. General information

NPI: 1821799883
Provider Name (Legal Business Name): ACTIVA HOME HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 LOUISIANA BLVD NE STE B1
ALBUQUERQUE NM
87110-3564
US

IV. Provider business mailing address

PO BOX 11099
ALBUQUERQUE NM
87192-0099
US

V. Phone/Fax

Practice location:
  • Phone: 505-362-7977
  • Fax:
Mailing address:
  • Phone: 505-362-7977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: ROSELLE OSTENDORF
Title or Position: PRESIDENT/ADMIN
Credential:
Phone: 505-362-7977