MEDICARE: ACTIVE COMMUNITY ENRICHMENT

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	251C00000X	Developmentally Disabled Services Day Training Agency		CO

General Provider Information

NPI Number	:	1710344502
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE COMMUNITY ENRICHMENT

Provider Business Mailing Address
First Line	:	1007 TIMBER LN
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-4152
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1007 TIMBER LN
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-4152
Country	:	US
Telephone Number	:	720-470-1888
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KEVIN RABON
Credential	:
Telephone Number	:	720-470-1888

Provider Enumeration Date	:	01/25/2016
Last Update Date	:	01/25/2016

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