Provider Demographics
NPI:1326655101
Name:PROACTIVE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:PROACTIVE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:RECTOR
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:719-535-2757
Mailing Address - Street 1:9320 GRAND CORDERA PKWY STE 125
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80924-7011
Mailing Address - Country:US
Mailing Address - Phone:719-535-2757
Mailing Address - Fax:
Practice Address - Street 1:1808 WOODMOOR DR
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-9057
Practice Address - Country:US
Practice Address - Phone:719-535-2757
Practice Address - Fax:719-535-2767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
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
CO9000161434Medicaid