Provider Demographics
NPI:1053364679
Name:ACTIVE PHYSICAL THERAPY AND REHAB SERVICES INC.
Entity type:Organization
Organization Name:ACTIVE PHYSICAL THERAPY AND REHAB SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHAMUNDEESWARI
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTHUVINAYAGAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICALTHERAPIST
Authorized Official - Phone:810-966-8500
Mailing Address - Street 1:718 HURON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3704
Mailing Address - Country:US
Mailing Address - Phone:810-966-8500
Mailing Address - Fax:810-966-8600
Practice Address - Street 1:718 HURON AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3704
Practice Address - Country:US
Practice Address - Phone:810-966-8500
Practice Address - Fax:810-966-8600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1053364679OtherBLUECARE NETWORK
MI30045OtherBCBS
MI5183763Medicaid
MI30901OtherBCBS
MI236782Medicare PIN
MI30045OtherBCBS