Provider Demographics
NPI:1326421074
Name:ACTIVE LIFE PHYSICAL THERAPY LTD
Entity Type:Organization
Organization Name:ACTIVE LIFE PHYSICAL THERAPY LTD
Other - Org Name:ACTIVE LIFE PHYSICAL THERAPY AND WELLNESS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CONSTANTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLOS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:847-323-7001
Mailing Address - Street 1:3620 EDISON PL
Mailing Address - Street 2:
Mailing Address - City:ROLLING MEADOWS
Mailing Address - State:IL
Mailing Address - Zip Code:60008-1037
Mailing Address - Country:US
Mailing Address - Phone:847-323-7001
Mailing Address - Fax:
Practice Address - Street 1:3620 EDISON PL
Practice Address - Street 2:
Practice Address - City:ROLLING MEADOWS
Practice Address - State:IL
Practice Address - Zip Code:60008-1037
Practice Address - Country:US
Practice Address - Phone:847-323-7001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy