Provider Demographics
NPI:1194912808
Name:PROACTIVE HEALTH LLC
Entity type:Organization
Organization Name:PROACTIVE HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:541-389-8714
Mailing Address - Street 1:62968 O B RILEY RD
Mailing Address - Street 2:E2-16
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-9442
Mailing Address - Country:US
Mailing Address - Phone:541-389-8714
Mailing Address - Fax:
Practice Address - Street 1:62968 O B RILEY RD
Practice Address - Street 2:#16
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-9442
Practice Address - Country:US
Practice Address - Phone:541-389-8714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000029202N1,,N2,N6261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center