Provider Demographics
NPI:1275863946
Name:ACTIVE LIFE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ACTIVE LIFE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DOLAN
Authorized Official - Last Name:FITTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:813-345-4558
Mailing Address - Street 1:21756 SR 54
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549
Mailing Address - Country:US
Mailing Address - Phone:813-345-4558
Mailing Address - Fax:813-949-1741
Practice Address - Street 1:21756 SR 54
Practice Address - Street 2:SUITE 102
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549
Practice Address - Country:US
Practice Address - Phone:813-345-4558
Practice Address - Fax:813-949-1741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-02
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty