NPIMap

Organization Active NPI

Pro-Active Sportsmed PLLC

  • Orthopedic Physical Therapist
  • Tumwater, WA
National Provider Identifier
1861612335
Registry record updated Mar 14, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Orthopedic Physical TherapistTaxonomy code 2251X0800X
Legal business name
PRO-ACTIVE SPORTSMED PLLC
Practice address
111 Tumwater Blvd SE Ste 113
Tumwater, WA 98501-6422
Phone
(605) 283-3003
Fax
(360) 528-8162
NPI assigned
Apr 26, 2007
Last updated
Mar 14, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 14, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Vince A Gildner, PT, ATC, CSCSNPI 1396746418
Title
Clinic Direcor
Phone
(360) 528-3300

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Orthopedic Physical Therapist 2251X0800X NU Primary

Addresses

Primary practice location

111 Tumwater Blvd SE Ste 113
Tumwater, WA 98501-6422

Mailing address

4200 6TH Ave SE Ste 203
Lacey, WA 98503-1042
Phone (360) 455-4448

Other identifiers 1

IdentifierTypeStateIssuer
7112923MedicaidWA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040322000725 WA Part B Supplier - Clinic/Group Practice 2062303969 Receives reassigned benefits from 10 practitioners
Practice locations: Lacey, WA; Tumwater, WA; Olympia, WA

National Provider Directory

National Provider Directory
Tax ID family
Pro-Active Sports Med2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

4219 6th Ave SE
Ste B
Lacey, WA 98503
Phone (360) 455-4448

2964 Limited Ln NW
Ste A
Olympia, WA 98502
Phone (360) 704-7276

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1177545600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1741910400000",
    "number": "1861612335",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4200 6TH AVE SE STE 203",
            "city": "LACEY",
            "state": "WA",
            "postal_code": "985031042",
            "telephone_number": "360-455-4448",
            "fax_number": "360-455-9833"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 TUMWATER BLVD SE STE 113",
            "city": "TUMWATER",
            "state": "WA",
            "postal_code": "985016422",
            "telephone_number": "605-283-3003",
            "fax_number": "360-528-8162"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRO-ACTIVE SPORTSMED PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-26",
        "last_updated": "2025-03-14",
        "certification_date": "2025-03-14",
        "status": "A",
        "authorized_official_last_name": "GILDNER",
        "authorized_official_first_name": "VINCE",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "CLINIC DIRECOR",
        "authorized_official_telephone_number": "360-528-3300",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "PT, ATC, CSCS"
    },
    "taxonomies": [
        {
            "code": "2251X0800X",
            "taxonomy_group": "",
            "desc": "Physical Therapist, Orthopedic",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7112923",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Tumwater, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 14, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.