Provider Demographics
NPI:1538603311
Name:ACTIVECARE PROVIDER SERVICES
Entity type:Organization
Organization Name:ACTIVECARE PROVIDER SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PREVOST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:346-319-0229
Mailing Address - Street 1:8700 COMMERCE PARK DR STE 218-B
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77036-7497
Mailing Address - Country:US
Mailing Address - Phone:346-319-0229
Mailing Address - Fax:
Practice Address - Street 1:8700 COMMERCE PARK DR STE 218-B
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-7497
Practice Address - Country:US
Practice Address - Phone:346-319-0229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-13
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care