Basic Information
| Provider Information | |||||||||
| NPI: | 1730162249 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACTIVE REHAB SERVICES INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ACTIVE RECOVERY PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 436 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | OAK HILL | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259013009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044653654 | ||||||||
| FaxNumber: | 3044658551 | ||||||||
| Practice Location | |||||||||
| Address1: | 436 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | OAK HILL | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259013009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044653654 | ||||||||
| FaxNumber: | 3044658551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 02/03/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FRAGALA | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3044653654 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | WV | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1043802 | 01 | WV | WV WORKERS COMPENSATION | OTHER | 001707473 | 01 | WV | MOUNTAIN STATE BC/BS | OTHER |