Provider Demographics
NPI:1508489790
Name:PHOENIX PRIMARY CARE LLC
Entity Type:Organization
Organization Name:PHOENIX PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-597-2861
Mailing Address - Street 1:PO BOX 354925
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32135-4925
Mailing Address - Country:US
Mailing Address - Phone:386-597-2861
Mailing Address - Fax:844-272-3971
Practice Address - Street 1:26B OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3808
Practice Address - Country:US
Practice Address - Phone:386-597-2861
Practice Address - Fax:844-272-3971
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ABUNDANT LIFE MINISTRIES-HOPE HOUSE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care