Provider Demographics
NPI:1487724654
Name:ACTIVE MEDICAL SUPPORT, LLC
Entity type:Organization
Organization Name:ACTIVE MEDICAL SUPPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:504-304-8424
Mailing Address - Street 1:433 12TH ST
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70053-5525
Mailing Address - Country:US
Mailing Address - Phone:504-304-8424
Mailing Address - Fax:504-365-7301
Practice Address - Street 1:433 12TH ST
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70053-5525
Practice Address - Country:US
Practice Address - Phone:504-304-8424
Practice Address - Fax:504-365-7301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1310093Medicaid
LA=========0OtherBLUE CROSS PROVIDER
LA1310093Medicaid
LA=========0OtherBLUE CROSS PROVIDER