Provider Demographics
NPI:1093882797
Name:PRO ACTIVE HEALTH & WELLNESS LLC
Entity Type:Organization
Organization Name:PRO ACTIVE HEALTH & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:COLIN
Authorized Official - Last Name:PARTRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-388-3813
Mailing Address - Street 1:1000 JOHNNIE DODDS BLVD
Mailing Address - Street 2:SUITE 105B
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464
Mailing Address - Country:US
Mailing Address - Phone:843-388-8813
Mailing Address - Fax:843-216-8870
Practice Address - Street 1:1000 JOHNNIE DODDS BLVD
Practice Address - Street 2:SUITE 105B
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464
Practice Address - Country:US
Practice Address - Phone:843-388-8813
Practice Address - Fax:843-216-8870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2861111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2861Medicaid
U98140Medicare UPIN
SCCH2861Medicaid