Provider Demographics
NPI:1255612321
Name:PROACTIVE HEALTHCARE SERVICES, LLC
Entity type:Organization
Organization Name:PROACTIVE HEALTHCARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RACHEAL
Authorized Official - Middle Name:CHRISTIANA
Authorized Official - Last Name:BUNDOR
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:484-816-2876
Mailing Address - Street 1:100 E. BROOKHAVEN ROAD
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:19015-2310
Mailing Address - Country:US
Mailing Address - Phone:484-816-2876
Mailing Address - Fax:484-540-8391
Practice Address - Street 1:100 E. BROOKHAVEN ROAD
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:PA
Practice Address - Zip Code:19015-2310
Practice Address - Country:US
Practice Address - Phone:484-816-2876
Practice Address - Fax:484-540-8391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-02
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA21453601253Z00000X, 251E00000X
PA04900501251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026281500001Medicaid
PA04900501OtherHOME HEALTH AGENCY