Provider Demographics
NPI:1114468873
Name:ACTIVEFIT REHAB PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:ACTIVEFIT REHAB PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & COO
Authorized Official - Prefix:
Authorized Official - First Name:RATREE
Authorized Official - Middle Name:
Authorized Official - Last Name:LERTKITCHAROENPON
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT
Authorized Official - Phone:386-451-2185
Mailing Address - Street 1:4649 CLYDE MORRIS BLVD UNIT 607
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-3003
Mailing Address - Country:US
Mailing Address - Phone:386-214-2663
Mailing Address - Fax:
Practice Address - Street 1:4649 CLYDE MORRIS BLVD UNIT 607
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-3003
Practice Address - Country:US
Practice Address - Phone:386-214-2663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-14
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT13789261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy