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? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WV | 7115350001 | Medicare NSC |