Provider Demographics
NPI:1023788767
Name:RE ACTIVE TRAINING & REHAB LLC
Entity type:Organization
Organization Name:RE ACTIVE TRAINING & REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:636-443-9910
Mailing Address - Street 1:1401 GETTYSBURG LNDG
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-6104
Mailing Address - Country:US
Mailing Address - Phone:636-443-9910
Mailing Address - Fax:636-200-3601
Practice Address - Street 1:1401 GETTYSBURG LNDG
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-6104
Practice Address - Country:US
Practice Address - Phone:636-443-9910
Practice Address - Fax:636-200-3601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-15
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy