Provider Demographics
NPI:1326748815
Name:BERRY PERSONALIZED PRIMARY CARE LLC
Entity Type:Organization
Organization Name:BERRY PERSONALIZED PRIMARY CARE LLC
Other - Org Name:BERRY PERSONALIZED PRIMARY CARE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AGNP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-618-2545
Mailing Address - Street 1:106 PAIGE RIDDICK RD
Mailing Address - Street 2:
Mailing Address - City:GATES
Mailing Address - State:NC
Mailing Address - Zip Code:27937-9595
Mailing Address - Country:US
Mailing Address - Phone:757-618-2545
Mailing Address - Fax:
Practice Address - Street 1:704 MAIN ST
Practice Address - Street 2:
Practice Address - City:GATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:27938-9420
Practice Address - Country:US
Practice Address - Phone:252-260-1569
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-06
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care