Healthcare Provider Details

I. General information

NPI: 1306572755
Provider Name (Legal Business Name): ACTIVE SPORT & SPINE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 PATERSON AVE STE 202
LITTLE FALLS NJ
07424-1658
US

IV. Provider business mailing address

275 PATERSON AVE STE 202
LITTLE FALLS NJ
07424-1658
US

V. Phone/Fax

Practice location:
  • Phone: 201-661-1417
  • Fax: 973-475-8130
Mailing address:
  • Phone: 201-661-1417
  • Fax: 973-475-8130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. PRAKASH RAMANI
Title or Position: OWNER
Credential: DC
Phone: 201-661-1417