MEDICARE: PROACTIVE MD GA, 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	:	1760062780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROACTIVE MD GA, LLC

Provider Business Mailing Address
First Line	:	86 VILLA RD STE 100
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29615-3052
Country	:	US
Telephone Number	:	864-501-0751
Fax Number	:

Provider Business Practice Location Address
First Line	:	86 VILLA RD STE 100
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29615-3052
Country	:	US
Telephone Number	:	864-501-0751
Fax Number	:

Authorized Official
Title or Position	:	CHIEF MEDICAL OFFICER
Name	:	MARK ALLEN KEMBLE
Credential	:	MD
Telephone Number	:	864-640-8355

Provider Enumeration Date	:	04/13/2021
Last Update Date	:	01/27/2026

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