Basic Information
| Provider Information | |||||||||
| NPI: | 1669129201 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROACTIVE MSO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 ALLAWOOD CT | ||||||||
| Address2: | |||||||||
| City: | SIMPSONVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296816207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645010751 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4117 S 240 W STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOROCCO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479638194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645010751 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2022 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | HOPKINS | ||||||||
| AuthorizedOfficialFirstName: | JAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSOC. OPS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8645010751 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.