Healthcare Provider Details

I. General information

NPI: 1013518166
Provider Name (Legal Business Name): PROACTIVE MD NC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 COMMERCE ST SW STE J
CONOVER NC
28613-8257
US

IV. Provider business mailing address

10 CENTIMETERS DR
MAULDIN SC
29662-3278
US

V. Phone/Fax

Practice location:
  • Phone: 828-282-2280
  • Fax: 828-282-2278
Mailing address:
  • Phone: 864-501-0751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
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