=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891550463
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSIO ACTIVE THERAPY & WELLNESS CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2024
-----------------------------------------------------
Last Update Date | 05/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6845 PEMBROKE RD
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33023-2678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-362-4302
-----------------------------------------------------
Fax | 305-675-3311
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6845 PEMBROKE RD
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33023-2678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-362-4302
-----------------------------------------------------
Fax | 305-675-3311
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | FERNANDO MOREL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-362-4302
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------