MEDICARE: ACTIVE MEDICAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1821418187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE MEDICAL LLC

Provider Business Mailing Address
First Line	:	3890 TEAYS VALLEY RD
Second Line	:
City	:	HURRICANE
State	:	WV
Zip	:	25526-9720
Country	:	US
Telephone Number	:	304-397-6599
Fax Number	:	304-397-6566

Provider Business Practice Location Address
First Line	:	3890 TEAYS VALLEY RD
Second Line	:
City	:	HURRICANE
State	:	WV
Zip	:	25526-9720
Country	:	US
Telephone Number	:	304-397-6599
Fax Number	:	304-397-6566

Authorized Official
Title or Position	:	MEMBER/MANAGER
Name	:	ROBERT JOSEPH TANT
Credential	:	ATP
Telephone Number	:	304-389-1246

Provider Enumeration Date	:	04/24/2014
Last Update Date	:	07/10/2019

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Directions to “ACTIVE MEDICAL LLC ” Practice Location

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