Provider Demographics
NPI:1922480383
Name:PROACTIVE HEALTH CHIROPRACTIC, CORP
Entity Type:Organization
Organization Name:PROACTIVE HEALTH CHIROPRACTIC, CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:507-251-5248
Mailing Address - Street 1:4915 N VISTA GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:OTIS ORCHARDS
Mailing Address - State:WA
Mailing Address - Zip Code:99027-5001
Mailing Address - Country:US
Mailing Address - Phone:507-251-5248
Mailing Address - Fax:
Practice Address - Street 1:23801 E APPLEWAY AVE
Practice Address - Street 2:110
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-9687
Practice Address - Country:US
Practice Address - Phone:507-251-5248
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH 60570733111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty