Provider Demographics
NPI:1780860643
Name:ACTIVE LIVING MEDICAL SUPPLY
Entity Type:Organization
Organization Name:ACTIVE LIVING MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:501-379-9217
Mailing Address - Street 1:11324 ARCADE DR
Mailing Address - Street 2:SUITE 24
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-4074
Mailing Address - Country:US
Mailing Address - Phone:501-379-9217
Mailing Address - Fax:501-379-9218
Practice Address - Street 1:11324 ARCADE DR
Practice Address - Street 2:SUITE 24
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-4074
Practice Address - Country:US
Practice Address - Phone:501-379-9217
Practice Address - Fax:501-379-9218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR800124349332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR167682716Medicaid
AR167682716Medicaid