Provider Demographics
NPI:1699378349
Name:PRO ACTIVE THERAPEUTICS
Entity type:Organization
Organization Name:PRO ACTIVE THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:MIGUEL
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:305-389-3978
Mailing Address - Street 1:11884 SW 253RD ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-5863
Mailing Address - Country:US
Mailing Address - Phone:305-389-3978
Mailing Address - Fax:
Practice Address - Street 1:4280 SW 73RD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-4548
Practice Address - Country:US
Practice Address - Phone:305-389-3978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center