Provider Demographics
NPI:1124205604
Name:ACTIVE PT CORP
Entity Type:Organization
Organization Name:ACTIVE PT CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:800-287-0171
Mailing Address - Street 1:PO BOX 7197
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55903-7197
Mailing Address - Country:US
Mailing Address - Phone:800-287-0171
Mailing Address - Fax:800-287-0171
Practice Address - Street 1:1215 N 7TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:LAKE CITY
Practice Address - State:MN
Practice Address - Zip Code:55041
Practice Address - Country:US
Practice Address - Phone:507-322-3460
Practice Address - Fax:507-322-3450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-27
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN17549500Medicaid
MN17549500Medicaid