MEDICARE: PROACTIVE MEDICAL CLINIC CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1164163952
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROACTIVE MEDICAL CLINIC CORP

Provider Business Mailing Address
First Line	:	3455 PEACHTREE INDUSTRIAL BLVD STE 910
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-6502
Country	:	US
Telephone Number	:	678-584-5000
Fax Number	:	678-212-4040

Provider Business Practice Location Address
First Line	:	3455 PEACHTREE INDUSTRIAL BLVD STE 910
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-6502
Country	:	US
Telephone Number	:	678-584-5000
Fax Number	:	678-212-4040

Authorized Official
Title or Position	:	CEO
Name	:	DR. ANDREW HYUN
Credential	:	DC
Telephone Number	:	678-584-5000

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	04/05/2022

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