Provider Demographics
NPI:1598818262
Name:ACTIVE LIFE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:ACTIVE LIFE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANDRE
Authorized Official - Last Name:HABERPOINTNER
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:360-437-2444
Mailing Address - Street 1:9483 OAK BAY RD
Mailing Address - Street 2:
Mailing Address - City:PORT LUDLOW
Mailing Address - State:WA
Mailing Address - Zip Code:98365-9794
Mailing Address - Country:US
Mailing Address - Phone:360-437-2444
Mailing Address - Fax:800-952-8902
Practice Address - Street 1:9483 OAK BAY RD
Practice Address - Street 2:
Practice Address - City:PORT LUDLOW
Practice Address - State:WA
Practice Address - Zip Code:98365-9794
Practice Address - Country:US
Practice Address - Phone:360-437-2444
Practice Address - Fax:800-952-8902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009409225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8859823Medicare ID - Type Unspecified