Provider Demographics
NPI:1659346468
Name:ACTIVE MEDICAL INC
Entity type:Organization
Organization Name:ACTIVE MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTING
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:WHITLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-496-7362
Mailing Address - Street 1:108 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOUISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27549-2516
Mailing Address - Country:US
Mailing Address - Phone:919-496-7362
Mailing Address - Fax:919-496-6379
Practice Address - Street 1:108 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-2516
Practice Address - Country:US
Practice Address - Phone:919-496-7362
Practice Address - Fax:919-496-6379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7702540Medicaid
NC7702540Medicaid