Provider Demographics
NPI:1841209533
Name:PROACTIVE THERAPY
Entity Type:Organization
Organization Name:PROACTIVE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:LOVEALL
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-346-8373
Mailing Address - Street 1:1489 WEBSTER ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3766
Mailing Address - Country:US
Mailing Address - Phone:415-346-8373
Mailing Address - Fax:415-346-0806
Practice Address - Street 1:1489 WEBSTER ST
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3766
Practice Address - Country:US
Practice Address - Phone:415-346-8373
Practice Address - Fax:415-346-0806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38432480261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29485ZOtherBLUE SHIELD
CAZZZ29485ZOtherBLUE SHIELD