MEDICARE: ACTIEF COMMUNITY SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1033759360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIEF COMMUNITY SERVICES LLC

Provider Business Mailing Address
First Line	:	3685 DAVIE BLVD
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33312-3439
Country	:	US
Telephone Number	:	786-208-9288
Fax Number	:

Provider Business Practice Location Address
First Line	:	3685 DAVIE BLVD
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33312-3439
Country	:	US
Telephone Number	:	786-208-9288
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	YANELY BUSTELO GUTIERREZ
Credential	:
Telephone Number	:	786-208-9288

Provider Enumeration Date	:	01/15/2020
Last Update Date	:	01/15/2020

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