Provider Demographics
NPI:1558032011
Name:PROACTIVE MD IA PC
Entity Type:Organization
Organization Name:PROACTIVE MD IA PC
Other - Org Name:
Other - Org Type:
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 1:10 CENTIMETERS DR
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-3278
Mailing Address - Country:US
Mailing Address - Phone:864-501-0751
Mailing Address - Fax:
Practice Address - Street 1:10 CENTIMETERS DR
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-3278
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:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care