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General NPI Number Information
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NPI Number | 1902978968
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Entity Type | Organization
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Legal Business Name | ACTIVE PHYSICAL THERAPY, INC
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Dates
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Enumeration Date | 11/14/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1105 E FOSTER RD STE B
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City | SANTA MARIA
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State | CA
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Zip | 93455-6400
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Country | US
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Telephone | 805-934-0663
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Fax |
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Provider Business Mailing Address
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Address Line | 247 SANTA FE AVE
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City | PISMO BEACH
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State | CA
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Zip | 93449-1948
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | JORDAN ALBRIGHT LARSON
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Credential | P.T., O.C.S.
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Telephone | 805-934-0663
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | PT 21537
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License Number State | CA
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