Provider Demographics
NPI:1619170040
Name:PROACTIVE SPORTS CARE AND REHABILITATION,PC
Entity Type:Organization
Organization Name:PROACTIVE SPORTS CARE AND REHABILITATION,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:LARGEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:732-933-3570
Mailing Address - Street 1:160 WHITE RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LITTLE SILVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07739-1165
Mailing Address - Country:US
Mailing Address - Phone:732-933-3570
Mailing Address - Fax:
Practice Address - Street 1:160 WHITE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:LITTLE SILVER
Practice Address - State:NJ
Practice Address - Zip Code:07739-1165
Practice Address - Country:US
Practice Address - Phone:732-933-3570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0069501OtherORTHONET PROVIDER NUMBER
NJ3K4076OtherHEALTHNET PROVIDER #
NJ098337Medicare PIN
NJ0069501OtherORTHONET PROVIDER NUMBER