Provider Demographics
NPI:1346492964
Name:PROACTIVE HEALTH RESOURCES, LLC
Entity Type:Organization
Organization Name:PROACTIVE HEALTH RESOURCES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERVEER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:503-342-6202
Mailing Address - Street 1:4077 JEFFERSON PKWY
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-1478
Mailing Address - Country:US
Mailing Address - Phone:503-342-6202
Mailing Address - Fax:
Practice Address - Street 1:4077 JEFFERSON PKWY
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-1478
Practice Address - Country:US
Practice Address - Phone:503-342-6202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9142291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory