Provider Demographics
NPI:1891304812
Name:ACTIVE RECOVERY PHYSICAL THERAPY & SPORTS REHAB
Entity Type:Organization
Organization Name:ACTIVE RECOVERY PHYSICAL THERAPY & SPORTS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, AT, PTA
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:NOWKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-996-1098
Mailing Address - Street 1:250 S LAKE ST STE E
Mailing Address - Street 2:
Mailing Address - City:EAST JORDAN
Mailing Address - State:MI
Mailing Address - Zip Code:49727-9376
Mailing Address - Country:US
Mailing Address - Phone:231-222-2121
Mailing Address - Fax:231-222-2009
Practice Address - Street 1:250 S LAKE ST STE E
Practice Address - Street 2:
Practice Address - City:EAST JORDAN
Practice Address - State:MI
Practice Address - Zip Code:49727-9376
Practice Address - Country:US
Practice Address - Phone:231-222-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-27
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty