Provider Demographics
NPI:1861612335
Name:PRO-ACTIVE SPORTSMED PLLC
Entity type:Organization
Organization Name:PRO-ACTIVE SPORTSMED PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GILDNER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC, CSCS
Authorized Official - Phone:360-528-3300
Mailing Address - Street 1:4200 6TH AVE SE STE 203
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1042
Mailing Address - Country:US
Mailing Address - Phone:360-455-4448
Mailing Address - Fax:360-455-9833
Practice Address - Street 1:111 TUMWATER BLVD SE STE 113
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-6422
Practice Address - Country:US
Practice Address - Phone:605-283-3003
Practice Address - Fax:360-528-8162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7112923Medicaid
WA7112923Medicaid