MEDICARE: PROACTIVE MSO, LLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1326577396
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROACTIVE MSO, LLC

Provider Business Mailing Address
First Line	:	124 ALLAWOOD CT
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29681-6207
Country	:	US
Telephone Number	:	864-501-0751
Fax Number	:

Provider Business Practice Location Address
First Line	:	1602 UPPER 11TH ST
Second Line	:
City	:	VINCENNES
State	:	IN
Zip	:	47591-4820
Country	:	US
Telephone Number	:	812-886-4557
Fax Number	:

Authorized Official
Title or Position	:	ASSOC. OPS. MGR
Name	:	JAN HOPKINS
Credential	:
Telephone Number	:	864-501-0751

Provider Enumeration Date	:	06/05/2017
Last Update Date	:	03/25/2022

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