1619017027 NPI number — ACTIVE SC ONE, INC.

Table of content: (NPI 1619017027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619017027 NPI number — ACTIVE SC ONE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE SC ONE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619017027
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3880 HOUNDSFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29577-5792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-626-8501
Provider Business Practice Location Address Fax Number:
843-916-8858
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: EX0429 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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