Organization
ACTIVE LIFESTYLE MEDICAL, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. ROBBIE L. ELY CPED, LPED, CFO (PRESIDENT)
(918) 520-8008
Entity
Organization
Contact information
Practice address
5455 S MINGO RD STE E, TULSA, OK 74146-5724
(918) 576-6765
(888) 605-4113
Mailing address
5455 S MINGO RD STE E, TULSA, OK 74146-5724
(918) 576-6765
(888) 605-4113
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
O20190822002462
MANAGED PLANS
KS
01
—
O20190822002462
MANAGED PLANS
MO
01
—
O20190822002462
MANAGED PLANS
OK
05
—
O20190822002462
—
KS
05
—
O20190822002462
—
MO
05
—
O20190822002462
—
OK
Enumeration date
01/14/2019
Last updated
05/18/2022
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