Provider Demographics
NPI:1174396097
Name:PROACTIVE ATHLETIC PERFORMANCE LLC
Entity type:Organization
Organization Name:PROACTIVE ATHLETIC PERFORMANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:BODKIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, ATC
Authorized Official - Phone:580-917-6326
Mailing Address - Street 1:9 DUNWOODY PARK SOUTH # 14
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-7407
Mailing Address - Country:US
Mailing Address - Phone:580-917-6326
Mailing Address - Fax:
Practice Address - Street 1:9 DUNWOODY PARK SOUTH # 14
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-7407
Practice Address - Country:US
Practice Address - Phone:580-917-6326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy