Healthcare Provider Details

I. General information

NPI: 1659651677
Provider Name (Legal Business Name): ACTIVE PHYSICAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7890 HAVEN AVE SUITE 1
RANCHO CUCAMONGA CA
91730-3051
US

IV. Provider business mailing address

7890 HAVEN AVE SUITE #1
RANCHO CUCAMONGA CA
91730
US

V. Phone/Fax

Practice location:
  • Phone: 619-265-0291
  • Fax:
Mailing address:
  • Phone: 909-581-3051
  • Fax: 909-581-3057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateCA

VIII. Authorized Official

Name: MRS. SINDY TADROS
Title or Position: CEO
Credential: D.O.
Phone: 909-581-3051