=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427265495
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACTIVE CARE MEDICAL ASSOCIATES OF FOREST PARK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1075 MAIN STREET
-----------------------------------------------------
City | FOREST PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-366-4124
-----------------------------------------------------
Fax | 404-366-0297
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | #342 5656 JONESBORO ROAD SUITE #111
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-366-4124
-----------------------------------------------------
Fax | 404-366-0297
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. JENNIFER DANIELLE CRAWFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-366-4124
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251S0007X
-----------------------------------------------------
Taxonomy Name | Sports Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------