Provider Demographics
NPI:1750127767
Name:PROACTIVE REHABILITATION LLC
Entity type:Organization
Organization Name:PROACTIVE REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER RELATIONS SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:LITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-696-9353
Mailing Address - Street 1:600 CENTRAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2740
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:
Practice Address - Street 1:210 N AVIATION BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-7015
Practice Address - Country:US
Practice Address - Phone:951-696-9353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty