Provider Demographics
NPI:1508383324
Name:ACTIVE REHAB, LLC
Entity Type:Organization
Organization Name:ACTIVE REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:VIDENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-785-0872
Mailing Address - Street 1:2520 HORSESHOE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-8144
Mailing Address - Country:US
Mailing Address - Phone:1925-785-0872
Mailing Address - Fax:
Practice Address - Street 1:2520 HORSESHOE DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-8144
Practice Address - Country:US
Practice Address - Phone:925-785-0872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38866225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty