Provider Demographics
NPI:1912067976
Name:PROACTIVE PHYSICAL AND AQUATIC
Entity type:Organization
Organization Name:PROACTIVE PHYSICAL AND AQUATIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MINDI
Authorized Official - Middle Name:G
Authorized Official - Last Name:BLOOMENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:480-443-3534
Mailing Address - Street 1:9746 N 90TH PL
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5083
Mailing Address - Country:US
Mailing Address - Phone:480-443-3534
Mailing Address - Fax:480-367-9515
Practice Address - Street 1:9746 N 90TH PL
Practice Address - Street 2:SUITE 103
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5083
Practice Address - Country:US
Practice Address - Phone:480-443-3534
Practice Address - Fax:480-367-9515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0087104174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ24722Medicare ID - Type Unspecified