Basic Information
| Provider Information | |||||||||
| NPI: | 1457920118 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STAY ACTIVE PHYSICAL THERAPY AND PERFORMANCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27 TACOMA ST | ||||||||
| Address2: | |||||||||
| City: | HYDE PARK | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021363203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8572046228 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27 TACOMA ST | ||||||||
| Address2: | |||||||||
| City: | HYDE PARK | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021363203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8572046228 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2021 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ABDUL-JABBAAR | ||||||||
| AuthorizedOfficialFirstName: | KHALEEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 8572046228 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.