Provider Demographics
NPI:1588846513
Name:PROACTIVE PHYSICAL THERAPY AND EXERCISE CENTER, INC
Entity Type:Organization
Organization Name:PROACTIVE PHYSICAL THERAPY AND EXERCISE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:970-224-4141
Mailing Address - Street 1:2108 MIDPOINT DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4323
Mailing Address - Country:US
Mailing Address - Phone:970-224-4141
Mailing Address - Fax:
Practice Address - Street 1:1024 CENTRE AVE STE 100
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-1887
Practice Address - Country:US
Practice Address - Phone:970-224-4141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO7782OtherSTATE LICENSE
CO7782OtherSTATE LICENSE