MEDICARE: ACTIVMEDICAL DENTON, INC

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	332BC3200X	Customized Equipment (DME)	0030874	TX
2	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	0030874	TX
3	332BX2000X	Oxygen Equipment & Supplies (DME)	0030874	TX
4	332B00000X	Durable Medical Equipment & Medical Supplies	0030874	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	517284	OTHER	TX	HMO BLUE ORTHO AND PROS
4	10007096	OTHER	TX	AMERIGROUP
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	505306	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1770577660
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVMEDICAL DENTON, INC

Provider Business Mailing Address
First Line	:	2317 W UNIVERSITY DR
Second Line	:	SUITE 101
City	:	DENTON
State	:	TX
Zip	:	76201-1600
Country	:	US
Telephone Number	:	940-484-0228
Fax Number	:	940-484-0766

Provider Business Practice Location Address
First Line	:	2317 W UNIVERSITY DR
Second Line	:	SUITE 101
City	:	DENTON
State	:	TX
Zip	:	76201-1600
Country	:	US
Telephone Number	:	940-484-0228
Fax Number	:	940-484-0766

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAMES BEALL GARNER
Credential	:
Telephone Number	:	940-484-0228

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	04/11/2019

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