Provider Demographics
NPI:1265035877
Name:PROACTIVE MD GA, LLC
Entity Type:Organization
Organization Name:PROACTIVE MD GA, LLC
Other - Org Name:TINDALL CONLEY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOC. OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOPKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-501-0751
Mailing Address - Street 1:124 ALLAWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-6207
Mailing Address - Country:US
Mailing Address - Phone:864-501-0751
Mailing Address - Fax:
Practice Address - Street 1:3361 GRANT RD
Practice Address - Street 2:
Practice Address - City:CONLEY
Practice Address - State:GA
Practice Address - Zip Code:30288-2133
Practice Address - Country:US
Practice Address - Phone:678-244-7933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-17
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty