Provider Demographics
NPI:1871780742
Name:ACTIVE MOBILITY UPSTATE LLC
Entity type:Organization
Organization Name:ACTIVE MOBILITY UPSTATE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOOPER
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPO
Authorized Official - Phone:843-577-9577
Mailing Address - Street 1:3801 W. MONTAGUE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-5938
Mailing Address - Country:US
Mailing Address - Phone:843-577-9577
Mailing Address - Fax:843-718-1438
Practice Address - Street 1:115 GARNER ROAD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303
Practice Address - Country:US
Practice Address - Phone:864-541-0028
Practice Address - Fax:864-541-0027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC042523929335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE3088Medicaid
SCDE3088Medicaid