Provider Demographics
NPI:1508315110
Name:PRIMEFORT HEALTH LLC
Entity Type:Organization
Organization Name:PRIMEFORT HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OPEYEMI
Authorized Official - Middle Name:ABIODUN
Authorized Official - Last Name:AWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-220-4142
Mailing Address - Street 1:PO BOX 1879
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77902-1879
Mailing Address - Country:US
Mailing Address - Phone:908-220-4142
Mailing Address - Fax:866-777-8553
Practice Address - Street 1:2710 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 114
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-5701
Practice Address - Country:US
Practice Address - Phone:908-220-4142
Practice Address - Fax:866-777-8553
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMEFORT HEALTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ7009207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty