Provider Demographics
NPI:1558995928
Name:PROHEALTH FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:PROHEALTH FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JOBERT
Authorized Official - Middle Name:ARAGON
Authorized Official - Last Name:VEGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-614-4131
Mailing Address - Street 1:PO BOX 631
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-0631
Mailing Address - Country:US
Mailing Address - Phone:803-308-7746
Mailing Address - Fax:
Practice Address - Street 1:1555 MIDDLETON ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4791
Practice Address - Country:US
Practice Address - Phone:803-308-7746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty