Provider Demographics
NPI:1205869880
Name:ACTIVE PHYSICAL THERAPY AND WELLNESS PC
Entity type:Organization
Organization Name:ACTIVE PHYSICAL THERAPY AND WELLNESS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BASTARACHE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:810-694-1037
Mailing Address - Street 1:5430 S SAGINAW RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-4464
Mailing Address - Country:US
Mailing Address - Phone:810-694-1037
Mailing Address - Fax:
Practice Address - Street 1:5430 S SAGINAW RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-4464
Practice Address - Country:US
Practice Address - Phone:810-694-1037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007536225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4849415Medicaid
MI0P27400Medicare ID - Type UnspecifiedGROUP NUMBER
MIP27400001Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER