Basic Information
Provider Information | |||||||||
NPI: | 1649913492 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROACTIVE MSO, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 124 ALLAWOOD CT | ||||||||
Address2: |   | ||||||||
City: | SIMPSONVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296816207 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8645010751 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1615 S US HIGHWAY 231 | ||||||||
Address2: |   | ||||||||
City: | CRAWFORDSVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 479339421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7653234689 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2022 | ||||||||
LastUpdateDate: | 04/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOPKINS | ||||||||
AuthorizedOfficialFirstName: | JAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ASSOC. OPS MGR | ||||||||
AuthorizedOfficialTelephone: | 8645010751 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.