Provider Demographics
NPI:1114950557
Name:ACTIVBODY PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:ACTIVBODY PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:H
Authorized Official - Last Name:HASENYAGER
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:714-960-7995
Mailing Address - Street 1:19531 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-2902
Mailing Address - Country:US
Mailing Address - Phone:714-960-7995
Mailing Address - Fax:714-960-1884
Practice Address - Street 1:19531 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-2902
Practice Address - Country:US
Practice Address - Phone:714-960-7995
Practice Address - Fax:714-960-1884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13708225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB0871Medicare PIN