Healthcare Provider Details

I. General information

NPI: 1003192121
Provider Name (Legal Business Name): ACTIVE HEALING PHYSICAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 04/04/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16902 HIGHLAND AVE BSMT
JAMAICA NY
11432-2632
US

IV. Provider business mailing address

8450 169TH ST APT 415
JAMAICA NY
11432-2049
US

V. Phone/Fax

Practice location:
  • Phone: 718-844-4832
  • Fax: 347-923-3217
Mailing address:
  • Phone: 718-314-6763
  • Fax: 347-923-3217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number018530
License Number StateNY

VIII. Authorized Official

Name: DR. IMRUL KABIR
Title or Position: PRESIDENT/ PHYSICAL THERAPY
Credential: DPT
Phone: 718-314-6763