Provider Demographics
NPI:1437362787
Name:ACTIVE LIVING REHABILITATION INC
Entity type:Organization
Organization Name:ACTIVE LIVING REHABILITATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-376-4012
Mailing Address - Street 1:10446 PONTOFINO CIR
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-7057
Mailing Address - Country:US
Mailing Address - Phone:727-376-4012
Mailing Address - Fax:727-375-7878
Practice Address - Street 1:10446 PONTOFINO CIR
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655
Practice Address - Country:US
Practice Address - Phone:727-376-4012
Practice Address - Fax:727-375-7878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4420Medicare ID - Type Unspecified