Healthcare Provider Details

I. General information

NPI: 1437362787
Provider Name (Legal Business Name): ACTIVE LIVING REHABILITATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 04/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10446 PONTOFINO CIR
TRINITY FL
34655
US

IV. Provider business mailing address

10446 PONTOFINO CIR
TRINITY FL
34655-7057
US

V. Phone/Fax

Practice location:
  • Phone: 727-376-4012
  • Fax: 727-375-7878
Mailing address:
  • Phone: 727-376-4012
  • Fax: 727-375-7878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS R WEST
Title or Position: BUSINESS MANAGER
Credential:
Phone: 727-376-4012