Provider Demographics
NPI:1245602267
Name:ACTIVE THERAPY SERVICES LLC
Entity Type:Organization
Organization Name:ACTIVE THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ALAIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MEJIA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:574-952-1457
Mailing Address - Street 1:14320 ROTTERDAM RD
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-6416
Mailing Address - Country:US
Mailing Address - Phone:317-403-4160
Mailing Address - Fax:317-288-4014
Practice Address - Street 1:14320 ROTTERDAM RD
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-6416
Practice Address - Country:US
Practice Address - Phone:317-403-4160
Practice Address - Fax:317-288-4014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011411A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty