Provider Demographics
NPI:1255929691
Name:PROACTIVE PHYSICAL THERAPY
Entity type:Organization
Organization Name:PROACTIVE PHYSICAL THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:812-406-6854
Mailing Address - Street 1:10012 SPRUCE GROVE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-3380
Mailing Address - Country:US
Mailing Address - Phone:812-406-6854
Mailing Address - Fax:
Practice Address - Street 1:812 LYNDON LN STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-3844
Practice Address - Country:US
Practice Address - Phone:812-406-6854
Practice Address - Fax:502-792-7283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-31
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty