Provider Demographics
NPI:1477004513
Name:PRO HEALTH PAIN & REHAB LLC.
Entity Type:Organization
Organization Name:PRO HEALTH PAIN & REHAB LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:A
Authorized Official - Last Name:RESASCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-281-9086
Mailing Address - Street 1:60 LORRAINE CT.
Mailing Address - Street 2:
Mailing Address - City:HOLBOOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12744 WESTPORT PARKWAY
Practice Address - Street 2:SUITE 1E
Practice Address - City:LAVISTA
Practice Address - State:NE
Practice Address - Zip Code:68138
Practice Address - Country:US
Practice Address - Phone:949-281-9086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X, 207Q00000X, 207R00000X, 208100000X
NE208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty