Provider Demographics
NPI:1659784767
Name:ACTIVCORE HEALTH NETWORK LLC
Entity Type:Organization
Organization Name:ACTIVCORE HEALTH NETWORK LLC
Other - Org Name:ACTIVCORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KORNBLUTH
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MPT
Authorized Official - Phone:800-455-8982
Mailing Address - Street 1:800 BUNN DR STE 102
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-1968
Mailing Address - Country:US
Mailing Address - Phone:800-455-8982
Mailing Address - Fax:609-644-3817
Practice Address - Street 1:800 BUNN DR STE 102
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-1968
Practice Address - Country:US
Practice Address - Phone:800-455-8982
Practice Address - Fax:609-644-3817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2020-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ413846OtherMEDICARE PTAN