Provider Demographics
NPI:1407253669
Name:PRO ACTIVE ADVANTAGE, LLC
Entity Type:Organization
Organization Name:PRO ACTIVE ADVANTAGE, LLC
Other - Org Name:PRO ACTIVE BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HUMAN RESOURCES
Authorized Official - Prefix:
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:MARECKI
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:208-772-4935
Mailing Address - Street 1:562 SHOUP AVE W
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5029
Mailing Address - Country:US
Mailing Address - Phone:208-734-0407
Mailing Address - Fax:208-734-3534
Practice Address - Street 1:215 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-6155
Practice Address - Country:US
Practice Address - Phone:208-934-5880
Practice Address - Fax:208-934-5876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5654251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health