1699926378 NPI number — PROACTIVE SENIOR CARE INC

Table of content: (NPI 1699926378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699926378 NPI number — PROACTIVE SENIOR CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROACTIVE SENIOR CARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699926378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 628
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JULIAN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92036-0628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-887-2838
Provider Business Mailing Address Fax Number:
760-765-4684

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
944 REGAL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENCINITAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92024-4634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-887-2838
Provider Business Practice Location Address Fax Number:
760-765-4684
Provider Enumeration Date:
10/01/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PORSUELO
Authorized Official First Name:
GEMMA
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
619-887-2838

Provider Taxonomy Codes

  • Taxonomy code: 363LG0600X , with the licence number:  15158 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)