Provider Demographics
NPI:1053879353
Name:ACTIVE SPORTS PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:ACTIVE SPORTS PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:254-300-1941
Mailing Address - Street 1:331 W STATE HIGHWAY 6 STE G
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-5584
Mailing Address - Country:US
Mailing Address - Phone:254-300-1941
Mailing Address - Fax:254-875-0472
Practice Address - Street 1:331 W STATE HIGHWAY 6 STE G
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5584
Practice Address - Country:US
Practice Address - Phone:254-300-1941
Practice Address - Fax:254-875-0472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy