Provider Demographics
NPI:1285878991
Name:PRO-ACTIVE REHAB INC.
Entity type:Organization
Organization Name:PRO-ACTIVE REHAB INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:501-778-4960
Mailing Address - Street 1:P.O. BOX 1890
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018
Mailing Address - Country:US
Mailing Address - Phone:501-778-4960
Mailing Address - Fax:501-778-4968
Practice Address - Street 1:720 WALCO RD
Practice Address - Street 2:SUITE 240
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104
Practice Address - Country:US
Practice Address - Phone:501-467-8275
Practice Address - Fax:501-467-8145
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRO-ACTIVE REHAB INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1316225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty