Basic Information
| Provider Information | |||||||||
| NPI: | 1194440297 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROACTIVE MD CO, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE CENTER FOR HEALTHY LIVING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 ALLAWOOD CT | ||||||||
| Address2: | |||||||||
| City: | SIMPSONVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296816207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645010751 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10485 SHERIDAN BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800204108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034668344 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2022 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | HOPKINS | ||||||||
| AuthorizedOfficialFirstName: | JAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8645010751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.