Provider Demographics
NPI:1053492371
Name:ACTIVE LIFE REHAB INC.
Entity Type:Organization
Organization Name:ACTIVE LIFE REHAB INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VISE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:CRISLER
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:352-860-2222
Mailing Address - Street 1:3589 E GULF TO LAKE HWY
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34453-3208
Mailing Address - Country:US
Mailing Address - Phone:352-860-2222
Mailing Address - Fax:352-860-2223
Practice Address - Street 1:3589 E GULF TO LAKE HWY
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34453-3208
Practice Address - Country:US
Practice Address - Phone:352-860-2222
Practice Address - Fax:352-860-2223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686592Medicare ID - Type Unspecified