Provider Demographics
NPI:1003441098
Name:STAY ACTIVE PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:STAY ACTIVE PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:AKSANOV
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:917-915-3894
Mailing Address - Street 1:9322 3RD AVE STE 476
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-6802
Mailing Address - Country:US
Mailing Address - Phone:917-915-3894
Mailing Address - Fax:
Practice Address - Street 1:297 BAY 20TH ST APT 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-6011
Practice Address - Country:US
Practice Address - Phone:917-915-3894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0444489OtherUNIVERSITY OF THE STATE OF NEW YORK, PHYSICAL THERAPIST