Provider Demographics
NPI:1073737391
Name:ACTIVE CARE MEDICAL ASSOCIATES OF CONYERS, LLC
Entity Type:Organization
Organization Name:ACTIVE CARE MEDICAL ASSOCIATES OF CONYERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-761-2302
Mailing Address - Street 1:PMB#359 1040 HONEY CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013
Mailing Address - Country:US
Mailing Address - Phone:770-761-2302
Mailing Address - Fax:770-761-2303
Practice Address - Street 1:1229 SALEM GATE DRIVE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013
Practice Address - Country:US
Practice Address - Phone:770-761-2302
Practice Address - Fax:770-761-2303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID#