1447327648 NPI number — PRIME CARE ONE, 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 1447327648 NPI number — PRIME CARE ONE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME CARE ONE, 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:
6
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:
1447327648
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1440 HIGHWAY A1A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32963-2310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-492-5002
Provider Business Mailing Address Fax Number:
772-492-5005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 PINEBROOK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34285-7147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-484-8801
Provider Business Practice Location Address Fax Number:
941-484-3450
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO, MGMT CO.
Authorized Official Telephone Number:
772-492-5002

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL8813 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 314000000X , with the licence number: SNF130470962 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 021332200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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