Provider Demographics
NPI:1902009079
Name:PROACTIVE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PROACTIVE ASSOCIATES, LLC
Other - Org Name:PHOENIX HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-632-7156
Mailing Address - Street 1:2450 N ROCK ROAD
Mailing Address - Street 2:SUITE # 213, ATTN: DEBRA MULLEN
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67060
Mailing Address - Country:US
Mailing Address - Phone:316-688-5511
Mailing Address - Fax:
Practice Address - Street 1:3450 N ROCK ROAD
Practice Address - Street 2:213
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-1352
Practice Address - Country:US
Practice Address - Phone:316-688-5511
Practice Address - Fax:316-688-1081
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX HOME CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-07
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSA087065251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100289090AMedicaid
KS100242630EMedicaid
KS100289090BMedicaid