=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598100109
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROACTIVE SPINE & SPORTS PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2013
-----------------------------------------------------
Last Update Date | 12/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2620 LARKSPUR LANE SUITE T
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96002-1043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-605-4422
-----------------------------------------------------
Fax | 530-722-4289
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2620 LARKSPUR LN STE T
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96002-1043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-605-4422
-----------------------------------------------------
Fax | 530-722-4289
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | DR. DALE P. LITTLE
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 530-605-4422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 39209
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------