Provider Demographics
NPI:1902370885
Name:ACTIVE LIFESTYLE MEDICAL, LLC
Entity Type:Organization
Organization Name:ACTIVE LIFESTYLE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBBIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELY
Authorized Official - Suffix:
Authorized Official - Credentials:CPED, LPED, CFO
Authorized Official - Phone:918-520-8008
Mailing Address - Street 1:5455 S MINGO RD STE E
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5724
Mailing Address - Country:US
Mailing Address - Phone:918-576-6765
Mailing Address - Fax:888-605-4113
Practice Address - Street 1:5455 S MINGO RD STE E
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5724
Practice Address - Country:US
Practice Address - Phone:918-576-6765
Practice Address - Fax:888-605-4113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-14
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKO20190822002462OtherMANAGED PLANS
MOO20190822002462OtherMANAGED PLANS
MOO20190822002462Medicaid
OKO20190822002462Medicaid
KSO20190822002462OtherMANAGED PLANS
KSO20190822002462Medicaid