Provider Demographics
NPI:1184736209
Name:ACTIVE LIVING OSTOMY, INC
Entity type:Organization
Organization Name:ACTIVE LIVING OSTOMY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GIRMA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGGESSE
Authorized Official - Suffix:
Authorized Official - Credentials:NONE
Authorized Official - Phone:951-808-9734
Mailing Address - Street 1:994 THOROUGHBRED LN
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-3861
Mailing Address - Country:US
Mailing Address - Phone:951-808-9734
Mailing Address - Fax:951-808-8603
Practice Address - Street 1:994 THOROUGHBRED LN
Practice Address - Street 2:
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860-3861
Practice Address - Country:US
Practice Address - Phone:951-808-9734
Practice Address - Fax:951-808-8603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA009039332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0332190001Medicare PIN
CA0332190001Medicare NSC