Provider Demographics
NPI:1013518166
Name:PROACTIVE MD NC, PC
Entity Type:Organization
Organization Name:PROACTIVE MD NC, PC
Other - Org Name:LEE INDUSTRIES 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 1:10 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 1:1220 COMMERCE ST SW STE J
Practice Address - Street 2:
Practice Address - City:CONOVER
Practice Address - State:NC
Practice Address - Zip Code:28613-8257
Practice Address - Country:US
Practice Address - Phone:828-282-2280
Practice Address - Fax:828-282-2278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-05
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1831661917OtherPROVIDER NPI