Provider Demographics
NPI:1548451602
Name:ACTIVE LYNX MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:ACTIVE LYNX MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KWABENA
Authorized Official - Middle Name:
Authorized Official - Last Name:KANKAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-440-0067
Mailing Address - Street 1:15626 SILVER RIDGE DR STE 108
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-3711
Mailing Address - Country:US
Mailing Address - Phone:281-440-0067
Mailing Address - Fax:
Practice Address - Street 1:15626 SILVER RIDGE DR STE 108
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-3711
Practice Address - Country:US
Practice Address - Phone:281-440-0067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0097834332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191581101Medicaid
TX191581102Medicaid
TX191581102Medicaid
TX6019590001Medicare NSC