MEDICARE: ACTIVEFIT REHAB PHYSICAL THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	PT13789	FL

General Provider Information

NPI Number	:	1114468873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVEFIT REHAB PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	4649 CLYDE MORRIS BLVD UNIT 607
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-3003
Country	:	US
Telephone Number	:	386-214-2663
Fax Number	:

Provider Business Practice Location Address
First Line	:	4649 CLYDE MORRIS BLVD UNIT 607
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-3003
Country	:	US
Telephone Number	:	386-214-2663
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT & COO
Name	:	RATREE LERTKITCHAROENPON
Credential	:	PT,DPT
Telephone Number	:	386-451-2185

Provider Enumeration Date	:	03/14/2017
Last Update Date	:	06/28/2017

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