Healthcare Provider Details

I. General information

NPI: 1831470483
Provider Name (Legal Business Name): PHYSIOACTIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 CONGRESS AVE SUITE 2102
BOCA RATON FL
33487-1352
US

IV. Provider business mailing address

22035 MARTELLA AVE
BOCA RATON FL
33433-4632
US

V. Phone/Fax

Practice location:
  • Phone: 561-241-5499
  • Fax: 561-241-5498
Mailing address:
  • Phone: 561-245-7418
  • Fax: 561-245-7418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROSSEANE V BRITO
Title or Position: SOLE PROPRIETOR
Credential: PT
Phone: 561-245-7418