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General NPI Number Information
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NPI Number | 1275863946
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Entity Type | Organization
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Legal Business Name | ACTIVE LIFE PHYSICAL THERAPY
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Dates
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Enumeration Date | 01/02/2010
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Last Update Date | 03/18/2013
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Provider Practice Location Address
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Address Line | 21756 SR 54 SUITE 102
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City | LUTZ
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State | FL
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Zip | 33549
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Country | US
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Telephone | 813-345-4558
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Fax | 813-949-1741
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Provider Business Mailing Address
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Address Line | 21756 SR 54 SUITE 102
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City | LUTZ
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State | FL
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Zip | 33549
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Country | US
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Telephone | 813-345-4558
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Fax | 813-949-1741
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Authorized Official
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Title or Position | OWNER
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Name | MR. MICHAEL DOLAN FITTIN
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Credential | PT
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Telephone | 813-345-4558
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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