Provider Demographics
NPI:1982459335
Name:PROACTIVE HEALTHCARE SERVICES LLC
Entity Type:Organization
Organization Name:PROACTIVE HEALTHCARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ISRAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNSOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:227-218-8737
Mailing Address - Street 1:7023 CORNER CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9472
Mailing Address - Country:US
Mailing Address - Phone:227-218-8737
Mailing Address - Fax:
Practice Address - Street 1:7023 CORNER CREEK WAY
Practice Address - Street 2:
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9472
Practice Address - Country:US
Practice Address - Phone:227-218-8737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty