Healthcare Provider Details

I. General information

NPI: 1972623981
Provider Name (Legal Business Name): PROACTIVE PHYSICAL THERAPY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2007
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 CROTON FALLS RD
MAHOPAC NY
10541-4002
US

IV. Provider business mailing address

310 CROTON FALLS RD
MAHOPAC NY
10541-4002
US

V. Phone/Fax

Practice location:
  • Phone: 914-843-4738
  • Fax:
Mailing address:
  • Phone: 914-843-4738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number020539
License Number StateNY

VIII. Authorized Official

Name: MR. WILLIAM MINNICH
Title or Position: PRESIDENT
Credential: P.T.
Phone: 914-843-4738