Basic Information
| Provider Information | |||||||||
| NPI: | 1558034082 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROACTIVE MD OK LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 CENTIMETERS DR | ||||||||
| Address2: | |||||||||
| City: | MAULDIN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296623278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645010751 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 TERRA DR | ||||||||
| Address2: | |||||||||
| City: | WOODWARD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 738019596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802901810 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2021 | ||||||||
| LastUpdateDate: | 07/30/2021 | ||||||||
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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: | 07/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.