=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114468873
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACTIVEFIT REHAB PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2017
-----------------------------------------------------
Last Update Date | 06/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4649 CLYDE MORRIS BLVD UNIT 607
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32129-3003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-214-2663
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4649 CLYDE MORRIS BLVD UNIT 607
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32129-3003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-214-2663
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & COO
-----------------------------------------------------
Name | RATREE LERTKITCHAROENPON
-----------------------------------------------------
Credential | PT,DPT
-----------------------------------------------------
Telephone | 386-451-2185
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT13789
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------