Provider Demographics
NPI:1679826457
Name:ACTIVE WELLNESS PHYSICAL THERAPY P.C.
Entity Type:Organization
Organization Name:ACTIVE WELLNESS PHYSICAL THERAPY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SABINIANO
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGGURAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-878-4103
Mailing Address - Street 1:100-05 ROOSEVELT AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368
Mailing Address - Country:US
Mailing Address - Phone:718-878-4103
Mailing Address - Fax:718-803-6440
Practice Address - Street 1:100-05 ROOSEVELT AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368
Practice Address - Country:US
Practice Address - Phone:718-878-4103
Practice Address - Fax:718-803-6440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0314231225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty