Provider Demographics
NPI:1962454074
Name:ACTIVE PT & SPORTS REHAB
Entity Type:Organization
Organization Name:ACTIVE PT & SPORTS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/AUTHORIZED OFFICIAL
Authorized Official - Prefix:MS
Authorized Official - First Name:JANNA
Authorized Official - Middle Name:P
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:713-297-7000
Mailing Address - Street 1:1300 W SAM HOUSTON PKWY S
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-2447
Mailing Address - Country:US
Mailing Address - Phone:713-297-7000
Mailing Address - Fax:713-297-7090
Practice Address - Street 1:2369 BEAM RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-3404
Practice Address - Country:US
Practice Address - Phone:812-378-4182
Practice Address - Fax:812-378-4194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN233140Medicare ID - Type UnspecifiedMEDICARE B SUPPLIER NUMBR