Provider Demographics
NPI:1518388651
Name:PRIME HEALTHCARE SERVICES LANDMARK LLC
Entity Type:Organization
Organization Name:PRIME HEALTHCARE SERVICES LANDMARK LLC
Other - Org Name:LANDMARK HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:VIENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-769-4100
Mailing Address - Street 1:219 CASS AVE
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-4736
Mailing Address - Country:US
Mailing Address - Phone:401-769-4100
Mailing Address - Fax:401-766-9575
Practice Address - Street 1:219 CASS AVE
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4736
Practice Address - Country:US
Practice Address - Phone:401-769-4100
Practice Address - Fax:401-766-9575
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIME HEALTHCARE SERVICES LANDMARK LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-16
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPR95788Medicaid
RIU100131494Medicare PIN