Provider Demographics
NPI:1326684010
Name:ACTIVE COMMUNITY SUPPORT
Entity Type:Organization
Organization Name:ACTIVE COMMUNITY SUPPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:K
Authorized Official - Last Name:NYAGA
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:484-350-0075
Mailing Address - Street 1:3505 W MORELAND RD
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-3831
Mailing Address - Country:US
Mailing Address - Phone:484-350-0075
Mailing Address - Fax:
Practice Address - Street 1:3505 W MORELAND RD
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-3831
Practice Address - Country:US
Practice Address - Phone:484-350-0075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities