Basic Information
| Provider Information | |||||||||
| NPI: | 1376215764 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACTIVCARE PHYSICAL THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 NEW FIDELITY CT | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275292665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192582714 | ||||||||
| FaxNumber: | 4106484878 | ||||||||
| Practice Location | |||||||||
| Address1: | 11009 INGLESIDE PLACE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197525943 | ||||||||
| FaxNumber: | 9197525946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2021 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | PARENT | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR VICE PRESIDENT OF REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 4104015120 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.