Basic Information
| Provider Information | |||||||||
| NPI: | 1366934242 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROACTIVE CLINICAL PARTNERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2445 DIRECTORS ROW STE C | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462414936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179417338 | ||||||||
| FaxNumber: | 3179696727 | ||||||||
| Practice Location | |||||||||
| Address1: | 1108 KINGWOOD DR | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176192133 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2018 | ||||||||
| LastUpdateDate: | 03/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | HUNT | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | BRANDON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3176192133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | REGISTERED NURSE | ||||||||
| NPICertificationDate: | 03/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | N | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment | 363LG0600X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.