Provider Demographics
NPI:1326474420
Name:ACTIVEDGE FITNESS AND SPORTS PERFORMANCE, INC.
Entity Type:Organization
Organization Name:ACTIVEDGE FITNESS AND SPORTS PERFORMANCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:919-493-1204
Mailing Address - Street 1:4221 GARRETT RD
Mailing Address - Street 2:SUITE 1-2
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-3467
Mailing Address - Country:US
Mailing Address - Phone:919-493-1204
Mailing Address - Fax:919-493-1204
Practice Address - Street 1:4221 GARRETT RD
Practice Address - Street 2:SUITE 1-2
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-3467
Practice Address - Country:US
Practice Address - Phone:919-493-1204
Practice Address - Fax:919-493-1204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC84532251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty