Healthcare Provider Details

I. General information

NPI: 1467166249
Provider Name (Legal Business Name): ACTIVE SC ONE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2023
Last Update Date: 01/06/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3532 LEAPHART RD
WEST COLUMBIA SC
29169-3032
US

IV. Provider business mailing address

6 INTERPLEX DR STE 401
TREVOSE PA
19053-6942
US

V. Phone/Fax

Practice location:
  • Phone: 803-791-3256
  • Fax:
Mailing address:
  • Phone: 267-917-6899
  • Fax:

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: STEPHANIE VANSCHAICK
Title or Position: REGULATORY AND CONTRACT ANALYST
Credential:
Phone: 215-642-6600