Provider Demographics
NPI:1831561208
Name:PRO-ACTIVE NEUROLOGY & SPORTS REHAB
Entity type:Organization
Organization Name:PRO-ACTIVE NEUROLOGY & SPORTS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:LOWRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-333-1477
Mailing Address - Street 1:7355 BARLITE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78224-1340
Mailing Address - Country:US
Mailing Address - Phone:210-333-1477
Mailing Address - Fax:210-558-0520
Practice Address - Street 1:7355 BARLITE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78224-1340
Practice Address - Country:US
Practice Address - Phone:210-333-1477
Practice Address - Fax:210-558-0520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9179305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131296907Medicaid