Provider Demographics
NPI:1003504531
Name:PRIMARY PHYSICIAN RESOURCE, LLC
Entity Type:Organization
Organization Name:PRIMARY PHYSICIAN RESOURCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLALVAZO-GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-348-2589
Mailing Address - Street 1:PO BOX 430764
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33243-0764
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 SW 27TH AVE STE 403B
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-2967
Practice Address - Country:US
Practice Address - Phone:786-348-2589
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-24
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care