Provider Demographics
NPI:1689315129
Name:ACTIVATE PT LLC
Entity Type:Organization
Organization Name:ACTIVATE PT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:WISSINK
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, MATCS
Authorized Official - Phone:402-580-1606
Mailing Address - Street 1:9015 ARBOR ST STE 155
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2072
Mailing Address - Country:US
Mailing Address - Phone:531-213-2666
Mailing Address - Fax:531-213-2386
Practice Address - Street 1:9015 ARBOR ST STE 155
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2072
Practice Address - Country:US
Practice Address - Phone:402-580-1606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-06
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty