Provider Demographics
NPI:1336695634
Name:A1 ACTIVE CARE
Entity Type:Organization
Organization Name:A1 ACTIVE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:M
Authorized Official - Last Name:LACY
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:678-230-7095
Mailing Address - Street 1:300 COLONIAL CENTER PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4892
Mailing Address - Country:US
Mailing Address - Phone:678-230-7095
Mailing Address - Fax:678-601-1365
Practice Address - Street 1:300 COLONIAL CENTER PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4892
Practice Address - Country:US
Practice Address - Phone:678-230-7095
Practice Address - Fax:678-601-1365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-28
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060-R--1609253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care