MEDICARE: ACTIVE CHANGE RECOVERY INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
2	251S00000X	Community/Behavioral Health Agency
3	324500000X	Substance Abuse Rehabilitation Facility
4	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1508648163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE CHANGE RECOVERY INC

Provider Business Mailing Address
First Line	:	1738 BARTLETT CT
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95206-6358
Country	:	US
Telephone Number	:	559-250-1121
Fax Number	:

Provider Business Practice Location Address
First Line	:	229 E WEBER AVE STE 103
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95202-2751
Country	:	US
Telephone Number	:	209-921-0971
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. MARTIN SISNEROZ JR.
Credential	:
Telephone Number	:	559-250-1121

Provider Enumeration Date	:	10/18/2023
Last Update Date	:	01/13/2026

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