Healthcare Provider Details

I. General information

NPI: 1255612321
Provider Name (Legal Business Name): PROACTIVE HEALTHCARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2011
Last Update Date: 11/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E. BROOKHAVEN ROAD
BROOKHAVEN PA
19015-2310
US

IV. Provider business mailing address

100 E. BROOKHAVEN ROAD
BROOKHAVEN PA
19015-2310
US

V. Phone/Fax

Practice location:
  • Phone: 484-816-2876
  • Fax: 484-540-8391
Mailing address:
  • Phone: 484-816-2876
  • Fax: 484-540-8391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number21453601
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number04900501
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number21453601
License Number StatePA

VIII. Authorized Official

Name: MS. RACHEAL CHRISTIANA BUNDOR
Title or Position: ADMINISTRATOR
Credential: LPN
Phone: 484-816-2876