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General NPI Number Information
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NPI Number | 1366796039
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Entity Type | Organization
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Legal Business Name | ACTIVA REHABILITATION SERVICES LLC
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Dates
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Enumeration Date | 11/02/2012
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Last Update Date | 04/14/2015
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Provider Practice Location Address
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Address Line | 331 CENTRAL AVENUE, 1
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City | ORANGE
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State | NJ
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Zip | 07050-2407
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Country | US
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Telephone | 973-673-4600
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Fax | 973-673-4606
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Provider Business Mailing Address
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Address Line | 336 PARK AVE
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City | ORANGE
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State | NJ
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Zip | 07050-2827
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Country | US
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Telephone | 973-673-4600
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Fax | 973-673-4606
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. OLUFEMI DOSUNMU
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Credential | PT
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Telephone | 973-214-2315
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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 | 40QA00445900
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License Number State | NJ
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