Provider Demographics
NPI:1538702576
Name:ACTIVE REHAB CLINIC
Entity Type:Organization
Organization Name:ACTIVE REHAB CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LATOSHIA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:HARDISON
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:405-209-0692
Mailing Address - Street 1:6929 S SOONER RD APT 43101
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-2739
Mailing Address - Country:US
Mailing Address - Phone:405-209-0692
Mailing Address - Fax:
Practice Address - Street 1:8720 S PENNSYLVANIA AVE STE B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-5237
Practice Address - Country:US
Practice Address - Phone:405-209-0692
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-22
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No251E00000XAgenciesHome Health