Provider Demographics
NPI:1013979905
Name:PROACTIVE HOME CARE, LLC
Entity type:Organization
Organization Name:PROACTIVE HOME CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CCO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-390-4040
Mailing Address - Street 1:3450 N ROCK ROAD
Mailing Address - Street 2:BUILDING 200, SUITE 213
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-1352
Mailing Address - Country:US
Mailing Address - Phone:316-688-5511
Mailing Address - Fax:316-688-1081
Practice Address - Street 1:3450 N ROCK ROAD
Practice Address - Street 2:BUILDING 200, SUITE 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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSA087055251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100242630BMedicaid
KS100242630AMedicaid
KS100242630CMedicaid
KS100242630BMedicaid