Provider Demographics
NPI:1215021159
Name:PRO ACTIVE REHAB, INC
Entity Type:Organization
Organization Name:PRO ACTIVE REHAB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:501-778-4960
Mailing Address - Street 1:PO BOX 1890
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-1890
Mailing Address - Country:US
Mailing Address - Phone:501-778-4960
Mailing Address - Fax:501-778-4968
Practice Address - Street 1:1308 MILITARY RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-2911
Practice Address - Country:US
Practice Address - Phone:501-778-4960
Practice Address - Fax:501-778-4968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 842225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F479Medicare ID - Type UnspecifiedPROVIDER NUMBER