Provider Demographics
NPI:1427265495
Name:ACTIVE CARE MEDICAL ASSOCIATES OF FOREST PARK
Entity type:Organization
Organization Name:ACTIVE CARE MEDICAL ASSOCIATES OF FOREST PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-366-4124
Mailing Address - Street 1:#342 5656 JONESBORO ROAD
Mailing Address - Street 2:SUITE #111
Mailing Address - City:LAKE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30260
Mailing Address - Country:US
Mailing Address - Phone:404-366-4124
Mailing Address - Fax:404-366-0297
Practice Address - Street 1:1075 MAIN STREET
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297
Practice Address - Country:US
Practice Address - Phone:404-366-4124
Practice Address - Fax:404-366-0297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty