Provider Demographics
NPI:1366549826
Name:ACTIVE MOBILITY SUPPLY, LLC.
Entity type:Organization
Organization Name:ACTIVE MOBILITY SUPPLY, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:WALDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-835-0100
Mailing Address - Street 1:6100 GETTY DRIVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117
Mailing Address - Country:US
Mailing Address - Phone:501-835-0100
Mailing Address - Fax:501-835-0103
Practice Address - Street 1:6100 GETTY DRIVE
Practice Address - Street 2:SUITE E
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117
Practice Address - Country:US
Practice Address - Phone:501-835-0100
Practice Address - Fax:501-835-0103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5785460001Medicare NSC