Basic Information
| Provider Information | |||||||||
| NPI: | 1285729509 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROACTIVE PHYSICAL THERAPY & SPORTS MEDICINE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6070 AVENIDA ENCINAS | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604440102 | ||||||||
| FaxNumber: | 7606883131 | ||||||||
| Practice Location | |||||||||
| Address1: | 6070 AVENIDA ENCINAS | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604440102 | ||||||||
| FaxNumber: | 7606883131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 01/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | VALJI | ||||||||
| AuthorizedOfficialFirstName: | AMYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7604440102 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251S0007X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports |
No ID Information.