1407500309 NPI number — PROACTIVE MD NM, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407500309 NPI number — PROACTIVE MD NM, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROACTIVE MD NM, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407500309
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 S SAINT FRANCIS DR STE 1000
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505-4147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-501-0751
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/09/2022

Additional Information

			
		

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)