Provider Demographics
NPI:1609093434
Name:PROACTIVE PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:PROACTIVE PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAULAN
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:208-677-2489
Mailing Address - Street 1:2311 PARK AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2170
Mailing Address - Country:US
Mailing Address - Phone:208-677-2489
Mailing Address - Fax:208-677-4023
Practice Address - Street 1:2311 PARK AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2170
Practice Address - Country:US
Practice Address - Phone:208-677-2489
Practice Address - Fax:208-677-4023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1299225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805407300Medicaid
ID805407300Medicaid