Organization Name: | PROACTIVE HEALTHCARE |
NPI Number: | 1891058384 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | NATHAN BURDASH (C.E.O.) |
Mailing Address: | 101 5th St E Suite 227 Saint Paul |
State: | MN US |
Postal Code: | 551011898 |
Phone Number: | 6517780080 |
Fax Number: | 6517780195 |
NPI Enumeration Date: | 06/19/2012 |
NPI Last Update Date: | 09/27/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | 41988 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MN |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |