Provider Demographics
NPI:1831470483
Name:PHYSIOACTIVE LLC
Entity Type:Organization
Organization Name:PHYSIOACTIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSSEANE
Authorized Official - Middle Name:V
Authorized Official - Last Name:BRITO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:561-245-7418
Mailing Address - Street 1:22035 MARTELLA AVE
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-4632
Mailing Address - Country:US
Mailing Address - Phone:561-245-7418
Mailing Address - Fax:561-245-7418
Practice Address - Street 1:7700 CONGRESS AVE
Practice Address - Street 2:SUITE 2102
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-1352
Practice Address - Country:US
Practice Address - Phone:561-241-5499
Practice Address - Fax:561-241-5498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-08
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty