Provider Demographics
NPI:1811968720
Name:ACTIVE MOBILITY, LLC
Entity type:Organization
Organization Name:ACTIVE MOBILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOOPER
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPO
Authorized Official - Phone:843-577-9577
Mailing Address - Street 1:3465 W MONTAGUE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-5938
Mailing Address - Country:US
Mailing Address - Phone:843-577-9577
Mailing Address - Fax:843-577-9574
Practice Address - Street 1:18 LEINBACH DR
Practice Address - Street 2:UNIT E
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7916
Practice Address - Country:US
Practice Address - Phone:843-377-0847
Practice Address - Fax:843-377-0845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC010714845335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2440Medicaid
SC=========OtherOTHER HEALTH PLANS
SCDE2440Medicaid
SC=========OtherOTHER HEALTH PLANS