Basic Information
Provider Information
NPI: 1649943176
EntityType: 2
ReplacementNPI:  
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
FaxNumber:  
Practice Location
Address1: 6606 E 540 RD
Address2:  
City: CLAREMORE
State: OK
PostalCode: 740192534
CountryCode: US
TelephoneNumber: 9189650220
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/30/2021
LastUpdateDate: 07/30/2021
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: HOPKINS
AuthorizedOfficialFirstName: JAN
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AuthorizedOfficialTitleorPosition: ASSOC. OPS MGR
AuthorizedOfficialTelephone: 8645010751
IsSoleProprietor:  
IsOrganizationSubpart: N
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NPICertificationDate: 07/30/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QP2300X  Y Ambulatory Health Care FacilitiesClinic/CenterPrimary Care

No ID Information.


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