Provider Demographics
NPI:1922266592
Name:ACTIVE HEALTH THERAPY LLC
Entity Type:Organization
Organization Name:ACTIVE HEALTH THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGRM/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LILIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUPE
Authorized Official - Suffix:
Authorized Official - Credentials:MS OTR/L MLD-CLT
Authorized Official - Phone:772-539-0393
Mailing Address - Street 1:916 TIDES RD STE E-100
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-1261
Mailing Address - Country:US
Mailing Address - Phone:772-539-0393
Mailing Address - Fax:
Practice Address - Street 1:916 TIDES RD
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32963-1261
Practice Address - Country:US
Practice Address - Phone:772-539-0393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9610261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL892281100Medicaid