Healthcare Provider Details

I. General information

NPI: 1891304812
Provider Name (Legal Business Name): ACTIVE RECOVERY PHYSICAL THERAPY & SPORTS REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 S LAKE ST STE E
EAST JORDAN MI
49727-9376
US

IV. Provider business mailing address

250 S LAKE ST STE E
EAST JORDAN MI
49727-9376
US

V. Phone/Fax

Practice location:
  • Phone: 231-222-2121
  • Fax:
Mailing address:
  • Phone: 231-222-2121
  • Fax: 231-222-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name: KRISTINA NOWKA
Title or Position: OWNER, AT, PTA
Credential:
Phone: 989-996-1098