Healthcare Provider Details

I. General information

NPI: 1518996503
Provider Name (Legal Business Name): ACTIVE PHYSICAL THERAPY INST., PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 BROADWAY
ELMWOOD PARK NJ
07407
US

IV. Provider business mailing address

67 BROADWAY
ELMWOOD PARK NJ
07407-1836
US

V. Phone/Fax

Practice location:
  • Phone: 201-794-3223
  • Fax: 201-794-8411
Mailing address:
  • Phone: 201-794-3223
  • Fax: 201-794-8411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PASKO L GAZIVODA
Title or Position: PRESIDENT
Credential: DPM
Phone: 201-794-3223