Provider Demographics
NPI:1598100109
Name:PROACTIVE SPINE & SPORTS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PROACTIVE SPINE & SPORTS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:P
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:530-605-4422
Mailing Address - Street 1:2620 LARKSPUR LN STE T
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-1043
Mailing Address - Country:US
Mailing Address - Phone:530-605-4422
Mailing Address - Fax:530-722-4289
Practice Address - Street 1:2620 LARKSPUR LANE
Practice Address - Street 2:SUITE T
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1043
Practice Address - Country:US
Practice Address - Phone:530-605-4422
Practice Address - Fax:530-722-4289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2022-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39209261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy