1467245837 NPI number — PROACTIVE PHYSICAL THERAPY AND WELLNESS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467245837 NPI number — PROACTIVE PHYSICAL THERAPY AND WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROACTIVE PHYSICAL THERAPY AND WELLNESS
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:
1467245837
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 W RICH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32720-4051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-987-4274
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
216 N WOODLAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32720-4219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-327-5284
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/27/2025

Additional Information

Authorized Official

Authorized Official Last Name:
WAGNER
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
DPT
Authorized Official Telephone Number:
910-987-4274

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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