Healthcare Provider Details

I. General information

NPI: 1023474152
Provider Name (Legal Business Name): PROACTIVE PROVIDER MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9320 GRAND CORDERA PKWY STE 125
COLORADO SPRINGS CO
80924-7003
US

IV. Provider business mailing address

9320 GRAND CORDERA PKWY STE 125
COLORADO SPRINGS CO
80924-7003
US

V. Phone/Fax

Practice location:
  • Phone: 719-535-2757
  • Fax: 719-535-2767
Mailing address:
  • Phone: 719-535-2757
  • Fax: 719-535-2767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. SCOTT O'CONNOR
Title or Position: MEMBER
Credential:
Phone: 805-266-4154