Provider Demographics
NPI:1063454874
Name:PROACTIVE PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:PROACTIVE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:RECTOR
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:719-535-2757
Mailing Address - Street 1:9320 GRAND CORDERA PKWY
Mailing Address - Street 2:SUITE 125
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80924-7003
Mailing Address - Country:US
Mailing Address - Phone:719-535-2757
Mailing Address - Fax:719-535-2767
Practice Address - Street 1:9320 GRAND CORDERA PKWY
Practice Address - Street 2:SUITE 125
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80924-7003
Practice Address - Country:US
Practice Address - Phone:719-535-2757
Practice Address - Fax:719-535-2767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO56352251S0007X
CO135372251X0800X
CO2586225X00000X
2251P0200X
CO11278225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12134040Medicaid
CO12134040Medicaid