Provider Demographics
NPI:1730760612
Name:ACTIVE PHYSICAL REHABILITATION
Entity type:Organization
Organization Name:ACTIVE PHYSICAL REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR/BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS-MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-223-6309
Mailing Address - Street 1:2516 HIGHWAY 35
Mailing Address - Street 2:
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-1925
Mailing Address - Country:US
Mailing Address - Phone:732-223-6309
Mailing Address - Fax:732-223-6409
Practice Address - Street 1:2516 HIGHWAY 35
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-1925
Practice Address - Country:US
Practice Address - Phone:732-223-6312
Practice Address - Fax:732-223-6409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty