Provider Demographics
NPI:1124183538
Name:ACTIVE BACK SUPPORT SERVICES,LLC
Entity Type:Organization
Organization Name:ACTIVE BACK SUPPORT SERVICES,LLC
Other - Org Name:ACTIVE BACK CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MAYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-582-9770
Mailing Address - Street 1:9389 HAGGERTY RD.
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170
Mailing Address - Country:US
Mailing Address - Phone:734-582-9770
Mailing Address - Fax:734-582-9773
Practice Address - Street 1:9389 HAGGERTY RD.
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170
Practice Address - Country:US
Practice Address - Phone:734-582-9770
Practice Address - Fax:734-582-9773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012727225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty