Provider Demographics
NPI:1588895791
Name:ACTIVE MOVEMENT REHABILITATION AND WELLNESS, LLC
Entity type:Organization
Organization Name:ACTIVE MOVEMENT REHABILITATION AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KANDYL
Authorized Official - Middle Name:K
Authorized Official - Last Name:DOMANGUE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:985-209-9239
Mailing Address - Street 1:PO BOX 918
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-0918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:127 HIGHWAY 22 E
Practice Address - Street 2:UNIT N5
Practice Address - City:MADISONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70447-9306
Practice Address - Country:US
Practice Address - Phone:985-209-9239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-05
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.200287225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty