Healthcare Provider Details

I. General information

NPI: 1841070208
Provider Name (Legal Business Name): PROACTIVEMED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2023
Last Update Date: 10/03/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URBANIZACION PEREYO CALLE ORION 9
HUMACAO PR
00791
US

IV. Provider business mailing address

PO BOX 1327
GURABO PR
00778-1327
US

V. Phone/Fax

Practice location:
  • Phone: 787-998-2040
  • Fax: 787-266-8423
Mailing address:
  • Phone: 787-998-2040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: PEDRO D SANTIAGO LUGO
Title or Position: OWNER / PRESIDENT
Credential: MD
Phone: 787-243-6966