MEDICARE: ACTIVECARERX PROVIDERS, 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	261QP0904X	Federal Public Health Clinic/Center

General Provider Information

NPI Number	:	1871995357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVECARERX PROVIDERS, LLC

Provider Business Mailing Address
First Line	:	4504 SAN BLAS AVE
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364-5429
Country	:	US
Telephone Number	:	818-512-1991
Fax Number	:	818-592-0494

Provider Business Practice Location Address
First Line	:	4504 SAN BLAS AVE
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364-5429
Country	:	US
Telephone Number	:	818-512-1991
Fax Number	:	818-592-0494

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JASON CARAMANIS
Credential	:
Telephone Number	:	818-512-1991

Provider Enumeration Date	:	09/16/2014
Last Update Date	:	09/16/2014

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