Provider Demographics
NPI:1811640667
Name:PROACTIVE MD SC,P.A.
Entity type:Organization
Organization Name:PROACTIVE MD SC,P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:KEMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-501-0751
Mailing Address - Street 1:124 ALLAWOOD CT.
Mailing Address - Street 2:ALLAWOOD CT
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681
Mailing Address - Country:US
Mailing Address - Phone:864-501-0751
Mailing Address - Fax:
Practice Address - Street 1:3520 W MONTAGUE AVE
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-6099
Practice Address - Country:US
Practice Address - Phone:843-885-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-01
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care