Provider Demographics
NPI:1023041381
Name:ACTIVE CARE REHAB, S.C.
Entity type:Organization
Organization Name:ACTIVE CARE REHAB, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:A
Authorized Official - Last Name:BALIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-228-7900
Mailing Address - Street 1:250 W COVENTRY CT
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3972
Mailing Address - Country:US
Mailing Address - Phone:414-228-7900
Mailing Address - Fax:414-228-7901
Practice Address - Street 1:250 W COVENTRY CT
Practice Address - Street 2:SUITE 204
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-3972
Practice Address - Country:US
Practice Address - Phone:414-228-7900
Practice Address - Fax:414-228-7901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2007-07-23
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
WI40423900Medicaid
WI40424000Medicaid