Provider Demographics
NPI:1710457106
Name:PROACTIVE PAIN CARE PA
Entity Type:Organization
Organization Name:PROACTIVE PAIN CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-676-5665
Mailing Address - Street 1:27160 BAY LANDING DR STE 200
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-4301
Mailing Address - Country:US
Mailing Address - Phone:239-676-5665
Mailing Address - Fax:239-221-3998
Practice Address - Street 1:27160 BAY LANDING DR STE 200
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4301
Practice Address - Country:US
Practice Address - Phone:239-676-5665
Practice Address - Fax:386-676-5634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-28
Last Update Date:2019-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty