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NPI Code Detail

MEDICARE: PROACTIVE MSO, LLC

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
1261QP2300XPrimary Care Clinic/Center

General Provider Information

NPI Number : 1689127474
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 : 2801 BERTHOLET BLVD STE 201
Second Line :
City : VALPARAISO
State : IN
Zip : 46383-7959
Country : US
Telephone Number : 844-458-2800
Fax Number :
Authorized Official
Title or Position : ASSOC. OPS MGR
Name : JAN HOPKINS
Credential :
Telephone Number : 864-501-0751
Provider Enumeration Date : 07/27/2016
Last Update Date : 03/25/2022

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Directions to “PROACTIVE MSO, LLC ” Practice Location

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