Provider Demographics
NPI:1003654104
Name:PROACTIVE HEALTHCARE EDUCATION CENTER
Entity type:Organization
Organization Name:PROACTIVE HEALTHCARE EDUCATION CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOLAMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-883-8932
Mailing Address - Street 1:334 E LAKE ST STE 105
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2485
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:334 E LAKE ST STE 105
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2485
Practice Address - Country:US
Practice Address - Phone:310-883-8932
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-15
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty