Provider Demographics
NPI:1891550463
Name:PHYSIO ACTIVE THERAPY & WELLNESS CORP
Entity Type:Organization
Organization Name:PHYSIO ACTIVE THERAPY & WELLNESS CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:MOREL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-362-4302
Mailing Address - Street 1:6845 PEMBROKE RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33023-2678
Mailing Address - Country:US
Mailing Address - Phone:954-362-4302
Mailing Address - Fax:305-675-3311
Practice Address - Street 1:6845 PEMBROKE RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33023-2678
Practice Address - Country:US
Practice Address - Phone:954-362-4302
Practice Address - Fax:305-675-3311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy