Healthcare Provider Details

I. General information

NPI: 1801223516
Provider Name (Legal Business Name): ACTIVE MOTION PHYSICAL THERAPY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2013
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22600 LAMBERT ST STE 1204
LAKE FOREST CA
92630-1623
US

IV. Provider business mailing address

22600 LAMBERT ST STE 1204
LAKE FOREST CA
92630-1623
US

V. Phone/Fax

Practice location:
  • Phone: 949-533-2055
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT228100
License Number StateCA

VIII. Authorized Official

Name: JORDAN JESSE TURNER
Title or Position: SHAREHOLDER
Credential: P.T.
Phone: 949-533-2055