Basic Information
| Provider Information | |||||||||
| NPI: | 1013518166 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROACTIVE MD NC, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEE INDUSTRIES HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 CENTIMETERS DR | ||||||||
| Address2: | |||||||||
| City: | MAULDIN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296623278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645010751 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1220 COMMERCE ST SW STE J | ||||||||
| Address2: | |||||||||
| City: | CONOVER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286138257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282822280 | ||||||||
| FaxNumber: | 8282822278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2020 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOPKINS | ||||||||
| AuthorizedOfficialFirstName: | JAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSOC. OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8645010751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1831661917 | 01 | IN | PROVIDER NPI | OTHER |