Provider Demographics
NPI:1003162272
Name:ACTIVE LIFE THERAPY SERVICES
Entity Type:Organization
Organization Name:ACTIVE LIFE THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHROUS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:941-586-7110
Mailing Address - Street 1:8451 WOODBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34238-5654
Mailing Address - Country:US
Mailing Address - Phone:941-586-7110
Mailing Address - Fax:941-921-4820
Practice Address - Street 1:4000 SAWYER RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-1272
Practice Address - Country:US
Practice Address - Phone:941-586-7110
Practice Address - Fax:941-921-4820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-25
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty