Provider Demographics
NPI:1104914878
Name:ACTIVE REHAB PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:ACTIVE REHAB PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:SCATES
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MS, DPT
Authorized Official - Phone:707-648-3144
Mailing Address - Street 1:1933 BANYON CMN
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-4787
Mailing Address - Country:US
Mailing Address - Phone:707-648-3144
Mailing Address - Fax:707-644-0630
Practice Address - Street 1:3419 BROADWAY ST
Practice Address - Street 2:SUITE H-10
Practice Address - City:AMERICAN CANYON
Practice Address - State:CA
Practice Address - Zip Code:94503-1261
Practice Address - Country:US
Practice Address - Phone:707-648-3144
Practice Address - Fax:707-644-0630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27031225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ30096ZMedicare ID - Type Unspecified