Provider Demographics
NPI:1821418187
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:ATP
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 1:3890 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9720
Practice Address - Country:US
Practice Address - Phone:304-397-6599
Practice Address - Fax:304-397-6566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7115350001Medicare NSC