Provider Demographics
NPI:1366796039
Name:ACTIVA REHABILITATION SERVICES LLC
Entity type:Organization
Organization Name:ACTIVA REHABILITATION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:OLUFEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:DOSUNMU
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:973-214-2315
Mailing Address - Street 1:336 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07050-2827
Mailing Address - Country:US
Mailing Address - Phone:973-673-4600
Mailing Address - Fax:973-673-4606
Practice Address - Street 1:331 CENTRAL AVENUE, 1
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07050-2407
Practice Address - Country:US
Practice Address - Phone:973-673-4600
Practice Address - Fax:973-673-4606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-02
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00445900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty