Provider Demographics
NPI:1508648163
Name:ACTIVE CHANGE RECOVERY INC
Entity Type:Organization
Organization Name:ACTIVE CHANGE RECOVERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SISNEROZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:559-250-1121
Mailing Address - Street 1:1738 BARTLETT CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-6358
Mailing Address - Country:US
Mailing Address - Phone:559-250-1121
Mailing Address - Fax:
Practice Address - Street 1:1823 ERICKSON CIR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206-6355
Practice Address - Country:US
Practice Address - Phone:559-250-1121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility