Provider Demographics
NPI:1366465387
Name:PROACTIVE PAIN RELIEF & WELLNESS, PC
Entity Type:Organization
Organization Name:PROACTIVE PAIN RELIEF & WELLNESS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:R
Authorized Official - Last Name:LAUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:717-733-6866
Mailing Address - Street 1:11 LONG AVE
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522-9795
Mailing Address - Country:US
Mailing Address - Phone:717-733-6866
Mailing Address - Fax:737-733-6996
Practice Address - Street 1:11 LONG AVE
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-9795
Practice Address - Country:US
Practice Address - Phone:717-733-6866
Practice Address - Fax:737-733-6996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC005653L111N00000X
PADC005668L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADB0067OtherRAILROAD
PA54139Medicare UPIN
PALA611823Medicare ID - Type Unspecified