Provider Demographics
NPI:1003044009
Name:ACTIVE ABILITIES LLC
Entity Type:Organization
Organization Name:ACTIVE ABILITIES LLC
Other - Org Name:ACTIVE ABILITIES PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/SOLE MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:MCLEAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:907-262-7748
Mailing Address - Street 1:PO BOX 1118
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:AK
Mailing Address - Zip Code:99672-1118
Mailing Address - Country:US
Mailing Address - Phone:907-262-7748
Mailing Address - Fax:907-262-7749
Practice Address - Street 1:33455 STERLING HIGHWAY
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:AK
Practice Address - Zip Code:99672-1118
Practice Address - Country:US
Practice Address - Phone:907-262-7748
Practice Address - Fax:907-262-7749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK833225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1021297Medicaid
AKPT89122Medicaid
AKPT8912Medicaid
AKPT89121Medicaid