Provider Demographics
| NPI: | 1518577733 |
|---|---|
| Name: | PROACTIVE REHABILITATION & WELLNESS LLC |
| Entity Type: | Organization |
| Organization Name: | PROACTIVE REHABILITATION & WELLNESS LLC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CEO & OWNER |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | RAFAEL |
| Authorized Official - Middle Name: | EDUARDO |
| Authorized Official - Last Name: | SALAZAR |
| Authorized Official - Suffix: | II |
| Authorized Official - Credentials: | MHS, OTR/L |
| Authorized Official - Phone: | 706-829-6706 |
| Mailing Address - Street 1: | 2320 NEAL ST |
| Mailing Address - Street 2: | |
| Mailing Address - City: | AUGUSTA |
| Mailing Address - State: | GA |
| Mailing Address - Zip Code: | 30906-3082 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 706-829-6706 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 2103 REEDALE AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | AUGUSTA |
| Practice Address - State: | GA |
| Practice Address - Zip Code: | 30906-3430 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 706-814-6887 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2020-08-03 |
| Last Update Date: | 2020-10-12 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | Group - Multi-Specialty |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 2251N0400X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology | Group - Multi-Specialty |
| No | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | Group - Multi-Specialty |
| Yes | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
| No | 225XE0001X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Environmental Modification | Group - Multi-Specialty |
| No | 225XE1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Ergonomics | Group - Multi-Specialty |
| No | 225XH1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | Group - Multi-Specialty |
| No | 225XP0019X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation | Group - Multi-Specialty |
| No | 261QR0400X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | Group - Multi-Specialty |
