Provider Demographics
NPI:1952555609
Name:ACTIVE HEALTH PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:ACTIVE HEALTH PHYSICAL THERAPY, INC.
Other - Org Name:ACTIVE HEALTH PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:MACLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:310-994-4663
Mailing Address - Street 1:911 7TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-2779
Mailing Address - Country:US
Mailing Address - Phone:310-994-4663
Mailing Address - Fax:310-310-3865
Practice Address - Street 1:10585 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4921
Practice Address - Country:US
Practice Address - Phone:310-994-4663
Practice Address - Fax:310-310-3865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-07
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA327632251E1200X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomicsGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA32763OtherPHYSICAL THERAPY LICENSE