Provider Demographics
NPI:1639410384
Name:ACTIVE FOR LIFE REHABILITATION, LLC
Entity Type:Organization
Organization Name:ACTIVE FOR LIFE REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:GRAEME
Authorized Official - Last Name:ANGELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:904-891-1179
Mailing Address - Street 1:4164 LONICERA LOOP
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4531
Mailing Address - Country:US
Mailing Address - Phone:904-891-1179
Mailing Address - Fax:
Practice Address - Street 1:4164 LONICERA LOOP
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-4531
Practice Address - Country:US
Practice Address - Phone:904-891-1179
Practice Address - Fax:904-212-1202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-05
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 21700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010501000Medicaid
HD565AMedicare PIN