Provider Demographics
NPI:1396099552
Name:PT ACTIVE CARE, PLLC
Entity type:Organization
Organization Name:PT ACTIVE CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENA
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-877-0100
Mailing Address - Street 1:8914 N 91ST AVE
Mailing Address - Street 2:100
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-8390
Mailing Address - Country:US
Mailing Address - Phone:623-877-0100
Mailing Address - Fax:623-298-0656
Practice Address - Street 1:8914 N 91ST AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-8390
Practice Address - Country:US
Practice Address - Phone:623-877-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEORIA URGENT CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy