Provider Demographics
NPI:1356009401
Name:ACTIVE LANE LLC
Entity Type:Organization
Organization Name:ACTIVE LANE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:THEOPHILE
Authorized Official - Middle Name:
Authorized Official - Last Name:NIZIGAMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-241-0907
Mailing Address - Street 1:6722 COLLEGE PARK CT SW APT 8
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-7511
Mailing Address - Country:US
Mailing Address - Phone:682-241-0907
Mailing Address - Fax:
Practice Address - Street 1:6722 COLLEGE PARK CT SW APT 8
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-7511
Practice Address - Country:US
Practice Address - Phone:682-241-0907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)