Provider Demographics
NPI:1396836052
Name:ACTIVE LIFE & SPORTS THERAPY LLC
Entity Type:Organization
Organization Name:ACTIVE LIFE & SPORTS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WAH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:410-529-3303
Mailing Address - Street 1:4 DULANEY GATE CT
Mailing Address - Street 2:
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-3011
Mailing Address - Country:US
Mailing Address - Phone:410-529-3303
Mailing Address - Fax:410-529-7980
Practice Address - Street 1:4337 EBENEZER RD
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-2143
Practice Address - Country:US
Practice Address - Phone:410-529-3303
Practice Address - Fax:410-529-7980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD6400507OtherAARP
MDKCH3ACOtherCAREFIRST OF MD
MDDA1789OtherRAILROAD MEDICARE
MDF517OtherGHMSI
MD434MOtherMEDICARE PTAN
MDKCH3ACOtherCAREFIRST OF MD
MD6400507OtherAARP