Provider Demographics
NPI:1982761391
Name:ACTIVE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:ACTIVE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SPADER
Authorized Official - Suffix:
Authorized Official - Credentials:MS,PT
Authorized Official - Phone:732-223-6309
Mailing Address - Street 1:2516 HIGHWAY 35
Mailing Address - Street 2:
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-1925
Mailing Address - Country:US
Mailing Address - Phone:732-223-6309
Mailing Address - Fax:732-223-6409
Practice Address - Street 1:2516 HIGHWAY 35
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-1925
Practice Address - Country:US
Practice Address - Phone:732-223-6309
Practice Address - Fax:732-223-6409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA00936200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ068361Medicare ID - Type UnspecifiedGROUP NUMBER