Basic Information
| Provider Information | |||||||||
| NPI: | 1174076145 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROACTIVE MSO, LLC | ||||||||
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| OtherOrganizationName: | PROACTIVE MD BRAZIL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 ALLAWOOD CT | ||||||||
| Address2: | |||||||||
| City: | SIMPSONVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296816207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645010751 | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 E JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | BRAZIL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478342650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124201410 | ||||||||
| FaxNumber: | 8124201488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2016 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | HOPKINS | ||||||||
| AuthorizedOfficialFirstName: | JAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSOC. OPS MGR | ||||||||
| AuthorizedOfficialTelephone: | 8645010751 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 01059956A | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.