Provider Demographics
NPI:1427170133
Name:PRO ACTIVE ADVANTAGE, LLC
Entity type:Organization
Organization Name:PRO ACTIVE ADVANTAGE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:J
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-934-5880
Mailing Address - Street 1:215 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-6155
Mailing Address - Country:US
Mailing Address - Phone:208-934-5880
Mailing Address - Fax:208-934-5876
Practice Address - Street 1:264 MAIN AVE S
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6232
Practice Address - Country:US
Practice Address - Phone:208-772-4935
Practice Address - Fax:208-734-3534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8062720Medicaid