Basic Information
| Provider Information | |||||||||
| NPI: | 1235190950 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROACTIVE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF VANCOUVER, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 52194 | ||||||||
| Address2: | DEPT CODE 963 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850722194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034891781 | ||||||||
| FaxNumber: | 5034891650 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986603213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608230138 | ||||||||
| FaxNumber: | 3608230141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 07/25/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KRAUT | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | DEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5037408847 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 602338111 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 7122260 | 05 | WA | MEDICAID |