Basic Information
| Provider Information | |||||||||
| NPI: | 1407500309 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROACTIVE MD NM, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 ALLAWOOD CT. | ||||||||
| Address2: | ALLAWOOD CT | ||||||||
| City: | SIMPSONVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645010751 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 S SAINT FRANCIS DR STE 1000 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645010751 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2022 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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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: | 01/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.