Provider Demographics
NPI:1376319087
Name:PROACTIVE MSO, LLC
Entity Type:Organization
Organization Name:PROACTIVE MSO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF IMPLEMENTATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ABBY
Authorized Official - Middle Name:ROBB
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-900-5687
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 1:725 N STATE ROAD 29
Practice Address - Street 2:
Practice Address - City:MICHIGANTOWN
Practice Address - State:IN
Practice Address - Zip Code:46057-9615
Practice Address - Country:US
Practice Address - Phone:864-501-0751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care