MEDICARE: PROACTIVE HEALTHCARE EDUCATION CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223D0001X	Public Health Dentistry

General Provider Information

NPI Number	:	1003654104
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROACTIVE HEALTHCARE EDUCATION CENTER

Provider Business Mailing Address
First Line	:	334 E LAKE ST STE 105
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2485
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	334 E LAKE ST STE 105
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2485
Country	:	US
Telephone Number	:	310-883-8932
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SOLAMAN SHIRE
Credential	:
Telephone Number	:	310-883-8932

Provider Enumeration Date	:	07/15/2024
Last Update Date	:	07/16/2024

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