Provider Demographics
NPI:1851454326
Name:PROACTIVE PHYSICAL THERAPY CENTERS, PLLC
Entity Type:Organization
Organization Name:PROACTIVE PHYSICAL THERAPY CENTERS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:BLASINGAME
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:713-436-3900
Mailing Address - Street 1:10223 BROADWAY ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7880
Mailing Address - Country:US
Mailing Address - Phone:713-436-3900
Mailing Address - Fax:713-436-3904
Practice Address - Street 1:10223 W BROADWAY
Practice Address - Street 2:SUITE B
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-7881
Practice Address - Country:US
Practice Address - Phone:713-436-3900
Practice Address - Fax:713-436-3904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2022-03-01
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
TX325729Medicare PIN
TX00W165Medicare ID - Type Unspecified
TX00W164Medicare ID - Type Unspecified