Provider Demographics
NPI:1609164904
Name:PROACTIVE PHYSICAL THERAPY,LLC
Entity Type:Organization
Organization Name:PROACTIVE PHYSICAL THERAPY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LACHANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-376-3000
Mailing Address - Street 1:1190 LISBON ST
Mailing Address - Street 2:UNIT 101
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5063
Mailing Address - Country:US
Mailing Address - Phone:207-376-3000
Mailing Address - Fax:207-376-3003
Practice Address - Street 1:1190 LISBON ST
Practice Address - Street 2:UNIT 101
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5063
Practice Address - Country:US
Practice Address - Phone:207-376-3000
Practice Address - Fax:207-376-3003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty