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General NPI Number Information
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NPI Number | 1194912808
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Entity Type | Organization
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Legal Business Name | PROACTIVE HEALTH LLC
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Dates
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Enumeration Date | 09/26/2007
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Last Update Date | 11/16/2016
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Provider Practice Location Address
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Address Line | 62968 O B RILEY RD #16
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City | BEND
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State | OR
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Zip | 97703-9442
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Country | US
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Telephone | 541-389-8714
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Fax |
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Provider Business Mailing Address
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Address Line | 62968 O B RILEY RD E2-16
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City | BEND
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State | OR
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Zip | 97703-9442
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Country | US
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Telephone | 541-389-8714
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | SUSAN HART
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Credential | NP
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Telephone | 541-389-8714
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 000029202N1,,N2,N6
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License Number State | OR
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