Provider Demographics
NPI:1073670402
Name:PRO-ACTIVE PHYSICAL THERAPY AND ATHLETIC TRAINING, PLLC
Entity Type:Organization
Organization Name:PRO-ACTIVE PHYSICAL THERAPY AND ATHLETIC TRAINING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:PACATTE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:518-234-7760
Mailing Address - Street 1:2403 STATE ROUTE 7
Mailing Address - Street 2:STORE #5
Mailing Address - City:COBLESKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12043-5740
Mailing Address - Country:US
Mailing Address - Phone:518-234-7760
Mailing Address - Fax:
Practice Address - Street 1:2403 STATE ROUTE 7
Practice Address - Street 2:STORE #5
Practice Address - City:COBLESKILL
Practice Address - State:NY
Practice Address - Zip Code:12043-5740
Practice Address - Country:US
Practice Address - Phone:518-234-7760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicare ID - Type Unspecified