Provider Demographics
NPI:1689016529
Name:ACTIVE PHYSICAL THERAPY AND WELLNESS, LLC
Entity Type:Organization
Organization Name:ACTIVE PHYSICAL THERAPY AND WELLNESS, LLC
Other - Org Name:ACTIVE PHYSICAL THERAPY AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:G
Authorized Official - Last Name:SANTILLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-751-3900
Mailing Address - Street 1:2 LODGE LN
Mailing Address - Street 2:
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-1629
Mailing Address - Country:US
Mailing Address - Phone:413-596-5363
Mailing Address - Fax:
Practice Address - Street 1:2 LODGE LN
Practice Address - Street 2:
Practice Address - City:WILBRAHAM
Practice Address - State:MA
Practice Address - Zip Code:01095-1629
Practice Address - Country:US
Practice Address - Phone:413-596-5363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-19
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy