Provider Demographics
NPI:1952737686
Name:PROACTIVE WELLNESS,LLC
Entity type:Organization
Organization Name:PROACTIVE WELLNESS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:609-234-0617
Mailing Address - Street 1:10 HASTINGS CT
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-5332
Mailing Address - Country:US
Mailing Address - Phone:609-234-0617
Mailing Address - Fax:
Practice Address - Street 1:230 N MAPLE AVE
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-9400
Practice Address - Country:US
Practice Address - Phone:856-983-5422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-26
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00089700171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty