Provider Demographics
NPI:1013058742
Name:ACTIVHEALTHCARE, INC.
Entity type:Organization
Organization Name:ACTIVHEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BRICKHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-455-0040
Mailing Address - Street 1:1926 NORTHLAKE PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-7069
Mailing Address - Country:US
Mailing Address - Phone:770-455-0040
Mailing Address - Fax:770-455-6188
Practice Address - Street 1:1926 NORTHLAKE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-7069
Practice Address - Country:US
Practice Address - Phone:770-455-0040
Practice Address - Fax:770-455-6188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization