Provider Demographics
NPI:1871633073
Name:ACTIVE LIVING STORE INC.
Entity Type:Organization
Organization Name:ACTIVE LIVING STORE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAGE
Authorized Official - Middle Name:R
Authorized Official - Last Name:WHITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-307-3511
Mailing Address - Street 1:PO BOX 492936
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34749-2936
Mailing Address - Country:US
Mailing Address - Phone:352-307-3511
Mailing Address - Fax:352-307-1151
Practice Address - Street 1:17860 SE 109TH AVE
Practice Address - Street 2:#630
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-8911
Practice Address - Country:US
Practice Address - Phone:352-307-3511
Practice Address - Fax:352-307-1151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1626332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4365520001Medicare ID - Type Unspecified