Provider Demographics
NPI:1568174118
Name:PRIME HEALTH LLC
Entity Type:Organization
Organization Name:PRIME HEALTH LLC
Other - Org Name:PRIME HEALTH CLINIC LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER / PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:747-500-4253
Mailing Address - Street 1:900 E MAIN ST STE 106
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5853
Mailing Address - Country:US
Mailing Address - Phone:747-500-4253
Mailing Address - Fax:747-356-4377
Practice Address - Street 1:900 E MAIN ST STE 106
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5853
Practice Address - Country:US
Practice Address - Phone:747-500-4253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-14
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service