Provider Demographics
NPI:1659651677
Name:ACTIVE PHYSICAL MEDICINE
Entity Type:Organization
Organization Name:ACTIVE PHYSICAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:TADROS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-581-3051
Mailing Address - Street 1:7890 HAVEN AVE
Mailing Address - Street 2:SUITE #1
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:909-581-3051
Mailing Address - Fax:909-581-3057
Practice Address - Street 1:7890 HAVEN AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3051
Practice Address - Country:US
Practice Address - Phone:619-265-0291
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-22
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111N00000X
2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty