Provider Demographics
NPI:1578157178
Name:ACTIVE MEDICAL LLC
Entity Type:Organization
Organization Name:ACTIVE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:TANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-389-1246
Mailing Address - Street 1:3890 TEAYS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9720
Mailing Address - Country:US
Mailing Address - Phone:304-397-6599
Mailing Address - Fax:304-397-6566
Practice Address - Street 1:89 HICKORY DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2834
Practice Address - Country:US
Practice Address - Phone:304-763-7029
Practice Address - Fax:304-619-5302
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACTIVE MEDICAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies