1073634713 NPI number — PRO ACTIVE ADVANTAGE, LLC

Table of content: (NPI 1073634713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073634713 NPI number — PRO ACTIVE ADVANTAGE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRO ACTIVE ADVANTAGE, LLC
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:
6
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:
1073634713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 UNIVERSITY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOODING
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83330-6155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-934-5880
Provider Business Mailing Address Fax Number:
208-934-5876

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1369 E 16TH ST STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-2008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-878-3423
Provider Business Practice Location Address Fax Number:
208-878-3424
Provider Enumeration Date:
04/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KNIGHT
Authorized Official First Name:
FRANK
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
208-934-5880

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8073811 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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