Provider Demographics
NPI:1275379810
Name:PROACTIVE MD WV CORPORATION
Entity type:Organization
Organization Name:PROACTIVE MD WV CORPORATION
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:864-501-0754
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:864-501-0754
Mailing Address - Fax:864-990-3834
Practice Address - Street 1:269 STAUNTON AVENUE SW
Practice Address - Street 2:SUITE 100
Practice Address - City:S. CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303
Practice Address - Country:US
Practice Address - Phone:304-768-0321
Practice Address - Fax:864-990-3834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care