MEDICARE: ACTIVE 1 PROSTHETICS AND ORTHOTICS

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	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1942697875
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE 1 PROSTHETICS AND ORTHOTICS

Provider Business Mailing Address
First Line	:	295 W CROMWELL AVE
Second Line	:	SUITE 102
City	:	FRESNO
State	:	CA
Zip	:	93711-6167
Country	:	US
Telephone Number	:	559-493-5020
Fax Number	:	559-492-3569

Provider Business Practice Location Address
First Line	:	295 W CROMWELL AVE
Second Line	:	SUITE 102
City	:	FRESNO
State	:	CA
Zip	:	93711-6167
Country	:	US
Telephone Number	:	559-493-5020
Fax Number	:	559-492-3569

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. STEPHAN MARK MAGILL
Credential	:	C.P.O.
Telephone Number	:	559-493-5020

Provider Enumeration Date	:	04/17/2015
Last Update Date	:	04/17/2015

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