Provider Demographics
| NPI: | 1245234848 |
|---|---|
| Name: | ACTIVA, LC |
| Entity Type: | Organization |
| Organization Name: | ACTIVA, LC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | ADMINISTRATIVE MANAGER |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | OSCAR |
| Authorized Official - Middle Name: | G |
| Authorized Official - Last Name: | FERREIRA |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 954-374-0160 |
| Mailing Address - Street 1: | 9720 STIRLING RD |
| Mailing Address - Street 2: | SUITE 104 |
| Mailing Address - City: | COOPER CITY |
| Mailing Address - State: | FL |
| Mailing Address - Zip Code: | 33024-8014 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 954-374-0160 |
| Mailing Address - Fax: | 954-374-0163 |
| Practice Address - Street 1: | 9720 STIRLING RD |
| Practice Address - Street 2: | SUITE 104 |
| Practice Address - City: | COOPER CITY |
| Practice Address - State: | FL |
| Practice Address - Zip Code: | 33024-8014 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 954-374-0160 |
| Practice Address - Fax: | 954-374-0163 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2005-06-10 |
| Last Update Date: | 2010-04-02 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 2251G0304X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics | Group - Multi-Specialty |
| No | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | Group - Multi-Specialty |
| No | 225200000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | Group - Multi-Specialty | |
| No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
| No | 225XG0600X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Gerontology | Group - Multi-Specialty |
| No | 225XL0004X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Low Vision | Group - Multi-Specialty |
| No | 225XP0019X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation | Group - Multi-Specialty |
| No | 225XP0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| FL | 686623996 | Medicaid | |
| FL | 889541400 | Medicaid | |
| FL | 889541400 | Medicaid |
