1861612335 NPI number — PRO-ACTIVE SPORTSMED PLLC

Table of content: (NPI 1861612335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861612335 NPI number — PRO-ACTIVE SPORTSMED PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRO-ACTIVE SPORTSMED PLLC
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:
1861612335
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4200 6TH AVE SE STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LACEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98503-1042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-455-4448
Provider Business Mailing Address Fax Number:
360-455-9833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 TUMWATER BLVD SE STE 113
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUMWATER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98501-6422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-283-3003
Provider Business Practice Location Address Fax Number:
360-528-8162
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GILDNER
Authorized Official First Name:
VINCE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CLINIC DIRECOR
Authorized Official Telephone Number:
360-528-3300

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7112923 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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