Provider Demographics
NPI:1467633495
Name:ACTIVE INNOVATIONS
Entity Type:Organization
Organization Name:ACTIVE INNOVATIONS
Other - Org Name:KEYMED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-541-0207
Mailing Address - Street 1:1892 BELLAIR BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4548
Mailing Address - Country:US
Mailing Address - Phone:904-541-0207
Mailing Address - Fax:904-269-8373
Practice Address - Street 1:1892 BELLAIR BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4548
Practice Address - Country:US
Practice Address - Phone:904-541-0207
Practice Address - Fax:904-269-8373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies