Provider Demographics
NPI:1073016614
Name:ACTIVE LIFE PHYSICAL THERAPY & REHAB INC
Entity Type:Organization
Organization Name:ACTIVE LIFE PHYSICAL THERAPY & REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:NIJJAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-637-7540
Mailing Address - Street 1:27320 DEBIASI DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:48174-8511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27320 DEBIASI DR
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN
Practice Address - State:MI
Practice Address - Zip Code:48174-8511
Practice Address - Country:US
Practice Address - Phone:734-637-7540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014085261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy