Provider Demographics
NPI:1518608199
Name:ACTIVE LIFE ADULT MEDICAL DAY CENTER, LLC
Entity Type:Organization
Organization Name:ACTIVE LIFE ADULT MEDICAL DAY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTIVITY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ENCOMIENDA
Authorized Official - Suffix:
Authorized Official - Credentials:BS IN MANAGEMENT
Authorized Official - Phone:443-739-6410
Mailing Address - Street 1:728 BACK RIVER NECK RD STE C
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:MD
Mailing Address - Zip Code:21221-1918
Mailing Address - Country:US
Mailing Address - Phone:410-754-4349
Mailing Address - Fax:443-505-4041
Practice Address - Street 1:728 BACK RIVER NECK RD STE C
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:MD
Practice Address - Zip Code:21221-1918
Practice Address - Country:US
Practice Address - Phone:410-754-4349
Practice Address - Fax:443-505-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care