Healthcare Provider Details

I. General information

NPI: 1427170133
Provider Name (Legal Business Name): PRO ACTIVE ADVANTAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 MAIN AVE S
TWIN FALLS ID
83301-6232
US

IV. Provider business mailing address

215 UNIVERSITY DR
GOODING ID
83330-6155
US

V. Phone/Fax

Practice location:
  • Phone: 208-772-4935
  • Fax: 208-734-3534
Mailing address:
  • Phone: 208-934-5880
  • Fax: 208-934-5876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name: FRANK J. KNIGHT
Title or Position: CEO
Credential:
Phone: 208-934-5880