Provider Demographics
NPI:1295847242
Name:PRO-ACTIVE PHYSICAL THERAPY OF MCCALL, PA
Entity Type:Organization
Organization Name:PRO-ACTIVE PHYSICAL THERAPY OF MCCALL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:ZAK
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:208-634-8517
Mailing Address - Street 1:P.O. BOX 2041
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638
Mailing Address - Country:US
Mailing Address - Phone:208-634-8517
Mailing Address - Fax:208-634-5763
Practice Address - Street 1:319 DEINHARD LN
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-4703
Practice Address - Country:US
Practice Address - Phone:208-634-8517
Practice Address - Fax:208-292-2817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808054300Medicaid
ID805164900Medicaid
1653383Medicare PIN
ID808054300Medicaid