1104914878 NPI number — ACTIVE REHAB PHYSICAL THERAPY, INC.

Table of content: (NPI 1104914878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104914878 NPI number — ACTIVE REHAB PHYSICAL THERAPY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE REHAB PHYSICAL THERAPY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104914878
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1933 BANYON CMN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVERMORE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94550-4787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-648-3144
Provider Business Mailing Address Fax Number:
707-644-0630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3419 BROADWAY ST
Provider Second Line Business Practice Location Address:
SUITE H-10
Provider Business Practice Location Address City Name:
AMERICAN CANYON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94503-1261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-648-3144
Provider Business Practice Location Address Fax Number:
707-644-0630
Provider Enumeration Date:
10/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SCATES
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
707-648-3144

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT27031 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)