Basic Information
| Provider Information | |||||||||
| NPI: | 1316145709 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACTIVE LIFE PHYSICAL THERAPY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 980 WILLOW CREEK RD | ||||||||
| Address2: | #104 | ||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287782227 | ||||||||
| FaxNumber: | 9287719159 | ||||||||
| Practice Location | |||||||||
| Address1: | 955 BLACK DRIVE | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287782227 | ||||||||
| FaxNumber: | 9287719159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WEARY | ||||||||
| AuthorizedOfficialFirstName: | DAYNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9287782227 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.