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General NPI Number Information
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NPI Number | 1689647950
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Entity Type | Organization
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Legal Business Name | PROACTIVE OF PENNSYLVANIA PC
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Dates
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Enumeration Date | 02/08/2006
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Last Update Date | 06/20/2008
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Provider Practice Location Address
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Address Line | 7325 OSWEGO RD
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City | LIVERPOOL
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State | NY
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Zip | 13090-3717
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Country | US
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Telephone | 315-451-6541
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Fax |
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Provider Business Mailing Address
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Address Line | 7325 OSWEGO RD
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City | LIVERPOOL
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State | NY
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Zip | 13090-3717
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Country | US
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Telephone | 315-451-6541
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Fax | 315-451-7059
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Authorized Official
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Title or Position | OWNER/PHYSCIAL THERAPY
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Name | MR. JEFFREY W HATHAWAY
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Credential | PT
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Telephone | 607-227-6366
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT017496
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License Number State | PA
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