Provider Demographics
NPI:1174076145
Name:PROACTIVE MSO, LLC
Entity type:Organization
Organization Name:PROACTIVE MSO, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KEMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-501-0751
Mailing Address - Street 1:124 ALLAWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-6207
Mailing Address - Country:US
Mailing Address - Phone:864-501-0751
Mailing Address - Fax:
Practice Address - Street 1:501 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-2650
Practice Address - Country:US
Practice Address - Phone:812-420-1410
Practice Address - Fax:812-420-1488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059956A261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care