Provider Demographics
NPI:1174664882
Name:PROACTIVE ALTERNATIVES PC
Entity Type:Organization
Organization Name:PROACTIVE ALTERNATIVES PC
Other - Org Name:PROACTIVE WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:I
Authorized Official - Last Name:STOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:847-549-6044
Mailing Address - Street 1:14044 W PETRONELLA DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-9656
Mailing Address - Country:US
Mailing Address - Phone:847-549-6044
Mailing Address - Fax:847-549-6058
Practice Address - Street 1:14044 W PETRONELLA DR
Practice Address - Street 2:SUITE 3
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-9656
Practice Address - Country:US
Practice Address - Phone:847-549-6044
Practice Address - Fax:847-549-6058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL593310Medicare ID - Type UnspecifiedEFFECTIVE BEFORE 1-01-06
IL212782Medicare ID - Type UnspecifiedEFFECTIVE 1-01-2006
ILP13081Medicare UPIN