Provider Demographics
NPI:1760613889
Name:ACTIVE FAMILY SOLUTIONS
Entity Type:Organization
Organization Name:ACTIVE FAMILY SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:GLENNRELLER
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:602-769-2532
Mailing Address - Street 1:13327 N 152ND AVE
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-9119
Mailing Address - Country:US
Mailing Address - Phone:602-769-2532
Mailing Address - Fax:
Practice Address - Street 1:13327 N 152ND AVE
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-9119
Practice Address - Country:US
Practice Address - Phone:602-769-2532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3836251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ184791OtherARIZONA DEPARTMENT OF ECONOMIC SECURITIES