MEDICARE: ACTIVE SC ONE, INC.

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	261QA0600X	Adult Day Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619017027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE SC ONE, INC.

Provider Business Mailing Address
First Line	:	6 NESHAMINY INTERPLEX DR STE 401
Second Line	:
City	:	TREVOSE
State	:	PA
Zip	:	19053-6942
Country	:	US
Telephone Number	:	215-642-6600
Fax Number	:	215-642-6610

Provider Business Practice Location Address
First Line	:	3880 HOUNDSFIELD AVE
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-5792
Country	:	US
Telephone Number	:	843-626-8501
Fax Number	:	843-916-8858

Authorized Official
Title or Position	:	CONTRACTS MANAGER
Name	:	DEBORA HOCKENBURY
Credential	:
Telephone Number	:	215-642-6600

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	06/30/2020

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Directions to “ACTIVE SC ONE, INC. ” Practice Location

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