Provider Demographics
NPI:1477172534
Name:ACTIVE PROVIDER SERVICE LLC
Entity Type:Organization
Organization Name:ACTIVE PROVIDER SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-993-4000
Mailing Address - Street 1:215 N LOOP 1604 E APT 4106
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1280
Mailing Address - Country:US
Mailing Address - Phone:210-993-4000
Mailing Address - Fax:
Practice Address - Street 1:215 N LOOP 1604 E APT 4106
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1280
Practice Address - Country:US
Practice Address - Phone:210-993-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-09
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty