Basic Information
| Provider Information | |||||||||
| NPI: | 1396273199 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEW PROACTIVE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PROACTIVE PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1480 NE VILLAGE ST | ||||||||
| Address2: | |||||||||
| City: | FAIRVIEW | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970243827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034891174 | ||||||||
| FaxNumber: | 5034891650 | ||||||||
| Practice Location | |||||||||
| Address1: | 1630 BEAVERCREEK RD STE A | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036070047 | ||||||||
| FaxNumber: | 5036070051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2017 | ||||||||
| LastUpdateDate: | 07/25/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TUTT | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5033811150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.