Provider Demographics
NPI:1003192121
Name:ACTIVE HEALING PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:ACTIVE HEALING PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ PHYSICAL THERAPY
Authorized Official - Prefix:DR
Authorized Official - First Name:IMRUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KABIR
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:718-314-6763
Mailing Address - Street 1:8450 169TH ST
Mailing Address - Street 2:APT 415
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-2049
Mailing Address - Country:US
Mailing Address - Phone:718-314-6763
Mailing Address - Fax:347-923-3217
Practice Address - Street 1:16902 HIGHLAND AVE BSMT
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-2632
Practice Address - Country:US
Practice Address - Phone:718-844-4832
Practice Address - Fax:347-923-3217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-02
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018530261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03435572Medicaid