1023568540 NPI number — ACTIVE SPINE PHYSICAL THERAPY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023568540 NPI number — ACTIVE SPINE PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE SPINE PHYSICAL THERAPY, LLC
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:
6
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:
1023568540
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10110 NICHOLAS ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68114-2185
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-932-2888
Provider Business Mailing Address Fax Number:
402-932-2899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10110 NICHOLAS ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-932-2888
Provider Business Practice Location Address Fax Number:
402-932-2899
Provider Enumeration Date:
10/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MUCHOWICZ
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
CHRISTOPHER
Authorized Official Title or Position:
PT
Authorized Official Telephone Number:
402-932-2888

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  3643 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3643 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3643 . This is a "STATE LICENSE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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