Provider Demographics
NPI:1912203977
Name:PROACTIVE WELLNESS LLC
Entity Type:Organization
Organization Name:PROACTIVE WELLNESS LLC
Other - Org Name:PROACTIVE WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:RICHMOND
Authorized Official - Last Name:LEHNER
Authorized Official - Suffix:
Authorized Official - Credentials:RD, DTR
Authorized Official - Phone:410-440-2037
Mailing Address - Street 1:41 PINKNEY ST
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-1717
Mailing Address - Country:US
Mailing Address - Phone:410-440-2037
Mailing Address - Fax:
Practice Address - Street 1:41 PINKNEY ST
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1717
Practice Address - Country:US
Practice Address - Phone:410-440-2037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2013-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3548133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty