1023568540 NPI number — ACTIVE SPINE PHYSICAL THERAPY, LLC

Table of content: (NPI 1023568540)

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:
ACTIVE PHYSICAL THERAPY
Provider Other Organization Name Type Code:
3
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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