=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245794122
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACTIVE RX REHAB AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2019
-----------------------------------------------------
Last Update Date | 01/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7139 HOPKINS RD STE 4
-----------------------------------------------------
City | MENTOR
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44060-4438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-423-5577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7139 HOPKINS RD STE 4
-----------------------------------------------------
City | MENTOR
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44060-4438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | LISA POLAKOWSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 440-423-5577
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------