Provider Demographics
NPI:1730312232
Name:ACTIVE HOME CARE LLC
Entity Type:Organization
Organization Name:ACTIVE HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-328-2866
Mailing Address - Street 1:5980 W 71ST ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-2711
Mailing Address - Country:US
Mailing Address - Phone:317-328-2866
Mailing Address - Fax:317-534-0578
Practice Address - Street 1:5980 W 71ST ST
Practice Address - Street 2:SUITE 203
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-2711
Practice Address - Country:US
Practice Address - Phone:317-328-2866
Practice Address - Fax:317-534-0578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-31
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN69000564A332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200999000Medicaid
IN6508910001Medicare NSC