Healthcare Provider Details

I. General information

NPI: 1447164371
Provider Name (Legal Business Name): ACTIVE RESIDENTIAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 RAY O VAC DR STE 2
MADISON WI
53711-2469
US

IV. Provider business mailing address

700 RAY O VAC DR STE 2 002
MADISON WI
53711-2469
US

V. Phone/Fax

Practice location:
  • Phone: 608-282-5061
  • Fax:
Mailing address:
  • Phone: 608-282-5061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateNULL

VIII. Authorized Official

Name: ABDISALAN H MUHUMED
Title or Position: OWNER
Credential:
Phone: 608-282-5061