Provider Demographics
NPI:1114190295
Name:PROACTIVE CARE, LLC
Entity Type:Organization
Organization Name:PROACTIVE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MELLUSI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:908-903-1199
Mailing Address - Street 1:1072 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:STIRLING
Mailing Address - State:NJ
Mailing Address - Zip Code:07980-1518
Mailing Address - Country:US
Mailing Address - Phone:908-903-1199
Mailing Address - Fax:908-901-1188
Practice Address - Street 1:1072 VALLEY RD
Practice Address - Street 2:
Practice Address - City:STIRLING
Practice Address - State:NJ
Practice Address - Zip Code:07980-1518
Practice Address - Country:US
Practice Address - Phone:908-903-1199
Practice Address - Fax:908-901-1188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00502400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ898970Medicare PIN