Provider Demographics
NPI:1699390187
Name:PRIME ACTIVE PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:PRIME ACTIVE PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARICAR
Authorized Official - Middle Name:
Authorized Official - Last Name:FANUGA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:562-382-3751
Mailing Address - Street 1:8916 REYDON ST
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-5236
Mailing Address - Country:US
Mailing Address - Phone:562-382-3751
Mailing Address - Fax:
Practice Address - Street 1:1817 W ORANGETHORPE AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-4405
Practice Address - Country:US
Practice Address - Phone:714-449-0911
Practice Address - Fax:714-449-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty