Provider Demographics
NPI:1801223516
Name:ACTIVE MOTION PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:ACTIVE MOTION PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:JESSE
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:949-533-2055
Mailing Address - Street 1:22600 LAMBERT ST STE 1204
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22600 LAMBERT ST STE 1204
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1623
Practice Address - Country:US
Practice Address - Phone:949-533-2055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT228100174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty