Provider Demographics
NPI:1659573301
Name:PROACTIVE ORTHOPEDIC PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:PROACTIVE ORTHOPEDIC PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:PTA, ATC
Authorized Official - Phone:714-921-9080
Mailing Address - Street 1:1607 E LINCOLN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92865-1958
Mailing Address - Country:US
Mailing Address - Phone:714-921-9080
Mailing Address - Fax:714-921-9336
Practice Address - Street 1:1607 E LINCOLN AVE STE B
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92865-1958
Practice Address - Country:US
Practice Address - Phone:714-921-9080
Practice Address - Fax:714-921-9336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAW16655261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16655Medicare ID - Type UnspecifiedMEDICARE