Healthcare Provider Details

I. General information

NPI: 1518577733
Provider Name (Legal Business Name): PROACTIVE REHABILITATION & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 10/12/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 REEDALE AVE
AUGUSTA GA
30906-3430
US

IV. Provider business mailing address

2320 NEAL ST
AUGUSTA GA
30906-3082
US

V. Phone/Fax

Practice location:
  • Phone: 706-814-6887
  • Fax:
Mailing address:
  • Phone: 706-829-6706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225XE0001X
TaxonomyEnvironmental Modification Occupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225XE1200X
TaxonomyErgonomics Occupational Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. RAFAEL EDUARDO SALAZAR II
Title or Position: CEO & OWNER
Credential: MHS, OTR/L
Phone: 706-829-6706