Provider Demographics
NPI:1356091946
Name:ACTIVE PHYSICAL THERAPY AND WELLNESS LLC
Entity Type:Organization
Organization Name:ACTIVE PHYSICAL THERAPY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PANDAY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:574-377-8779
Mailing Address - Street 1:1344 JACOBS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-8745
Mailing Address - Country:US
Mailing Address - Phone:574-377-8779
Mailing Address - Fax:
Practice Address - Street 1:1344 JACOBS DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-8745
Practice Address - Country:US
Practice Address - Phone:574-377-8779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty