Healthcare Provider Details

I. General information

NPI: 1659573301
Provider Name (Legal Business Name): PROACTIVE ORTHOPEDIC PHYSICAL THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 E LINCOLN AVE STE B
ORANGE CA
92865-1958
US

IV. Provider business mailing address

1607 E LINCOLN AVE STE B
ORANGE CA
92865-1958
US

V. Phone/Fax

Practice location:
  • Phone: 714-921-9080
  • Fax: 714-921-9336
Mailing address:
  • Phone: 714-921-9080
  • Fax: 714-921-9336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberW16655
License Number StateCA

VIII. Authorized Official

Name: MR. CAMERON THOMAS ANDREWS
Title or Position: OWNER
Credential: PTA, ATC
Phone: 714-921-9080