MEDICARE: ACTIVATE CARE HOSPICE, 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	251G00000X	Community Based Hospice Care Agency

General Provider Information

NPI Number	:	1962053785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVATE CARE HOSPICE, INC.

Provider Business Mailing Address
First Line	:	2904 THERESA DR # 104B
Second Line	:
City	:	NEWBURY PARK
State	:	CA
Zip	:	91320-3137
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2904 THERESA DR # 104B
Second Line	:
City	:	NEWBURY PARK
State	:	CA
Zip	:	91320-3137
Country	:	US
Telephone Number	:	310-721-1918
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ROMAN INKS
Credential	:
Telephone Number	:	818-212-5085

Provider Enumeration Date	:	09/23/2019
Last Update Date	:	09/23/2019

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