Provider Demographics
NPI:1407898778
Name:ACTIVECARE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:ACTIVECARE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGING DIRECTOT/PT
Authorized Official - Prefix:MR
Authorized Official - First Name:RIK
Authorized Official - Middle Name:
Authorized Official - Last Name:COUWENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:973-366-4000
Mailing Address - Street 1:600 MOUNT PLEASANT AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:DOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07801-1629
Mailing Address - Country:US
Mailing Address - Phone:973-366-4000
Mailing Address - Fax:973-366-4998
Practice Address - Street 1:600 MOUNT PLEASANT AVE
Practice Address - Street 2:SUITE F
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801-1629
Practice Address - Country:US
Practice Address - Phone:973-366-4000
Practice Address - Fax:973-366-4998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ055416Medicare ID - Type Unspecified