Healthcare Provider Details

I. General information

NPI: 1316860513
Provider Name (Legal Business Name): PROACTIVE MD FL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

494 N MANATEE AVE
ARCADIA FL
34266-4043
US

IV. Provider business mailing address

86 VILLA RD
GREENVILLE SC
29615-3052
US

V. Phone/Fax

Practice location:
  • Phone: 864-501-0751
  • Fax:
Mailing address:
  • Phone: 864-501-0751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARK KEMBLE
Title or Position: CMO
Credential: MD
Phone: 864-501-0751