Provider Demographics
NPI:1881201895
Name:ACTIVEFIT PHYSICAL THERAPY AND PERSONAL TRAINING
Entity Type:Organization
Organization Name:ACTIVEFIT PHYSICAL THERAPY AND PERSONAL TRAINING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-920-7110
Mailing Address - Street 1:12172 S. ROUTE 47
Mailing Address - Street 2:#125
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142
Mailing Address - Country:US
Mailing Address - Phone:847-920-7110
Mailing Address - Fax:847-920-7110
Practice Address - Street 1:12172 S. ROUTE 47
Practice Address - Street 2:#125
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142
Practice Address - Country:US
Practice Address - Phone:847-920-7110
Practice Address - Fax:847-920-7110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070020797OtherLICENSE NUMBER