Provider Demographics
NPI:1265731509
Name:ACTIVELIFE MEDICAL SUPPLIES LLC
Entity type:Organization
Organization Name:ACTIVELIFE MEDICAL SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMANO
Authorized Official - Suffix:
Authorized Official - Credentials:C PED
Authorized Official - Phone:773-699-2599
Mailing Address - Street 1:4152 W ARMITAGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-3694
Mailing Address - Country:US
Mailing Address - Phone:773-930-4271
Mailing Address - Fax:773-930-4275
Practice Address - Street 1:4152 W ARMITAGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-3694
Practice Address - Country:US
Practice Address - Phone:773-930-9271
Practice Address - Fax:773-930-4275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-25
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies