Provider Demographics
NPI:1336472190
Name:PRIMUS MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PRIMUS MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCIBELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-634-8888
Mailing Address - Street 1:10817 S JOG RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-0911
Mailing Address - Country:US
Mailing Address - Phone:561-634-8888
Mailing Address - Fax:561-634-8998
Practice Address - Street 1:10817 S JOG RD
Practice Address - Street 2:SUITE 230
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-0911
Practice Address - Country:US
Practice Address - Phone:561-634-8888
Practice Address - Fax:561-634-8998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-11
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care