Provider Demographics
NPI:1134641947
Name:PRIMARY CARE MANAGEMENT SERVICES, LLC
Entity Type:Organization
Organization Name:PRIMARY CARE MANAGEMENT SERVICES, LLC
Other - Org Name:MANNA HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:BACHENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:507-238-4844
Mailing Address - Street 1:400 S STATE ST STE 55
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-2872
Mailing Address - Country:US
Mailing Address - Phone:507-238-4844
Mailing Address - Fax:507-235-5542
Practice Address - Street 1:400 S STATE ST STE 55
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-2872
Practice Address - Country:US
Practice Address - Phone:507-238-4844
Practice Address - Fax:507-235-5542
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMARY CARE MANAGEMENT SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty