1306569868 NPI number — PRIME CARE 12 PRIORITY HEALTH INC.

Table of content: MARIA JACQUELINE LICON HERRERA (NPI 1710654223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306569868 NPI number — PRIME CARE 12 PRIORITY HEALTH INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME CARE 12 PRIORITY HEALTH INC.
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:
1306569868
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
702 STAFFORD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCETON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24740-2406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-425-0085
Provider Business Mailing Address Fax Number:
304-487-6993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 STAFFORD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24740-2406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-425-0085
Provider Business Practice Location Address Fax Number:
304-487-6993
Provider Enumeration Date:
09/20/2022

Additional Information

Authorized Official

Authorized Official Last Name:
VEST
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
Authorized Official Title or Position:
NP/OWNER
Authorized Official Telephone Number:
304-425-0085

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)





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