Provider Demographics
NPI:1508139494
Name:ACTIVE SPINE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:ACTIVE SPINE PHYSICAL THERAPY, LLC
Other - Org Name:ACTIVE THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:MUCHOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:402-932-2888
Mailing Address - Street 1:11810 NICHOLAS ST STE 103
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-4453
Mailing Address - Country:US
Mailing Address - Phone:402-932-2888
Mailing Address - Fax:402-932-2899
Practice Address - Street 1:11810 NICHOLAS ST STE 103
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4453
Practice Address - Country:US
Practice Address - Phone:402-932-2888
Practice Address - Fax:402-932-2899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026165702Medicaid
IA107512Medicaid