Provider Demographics
NPI:1609119882
Name:IMC PRIMERA LLC
Entity Type:Organization
Organization Name:IMC PRIMERA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAILESH
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTHARI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:888-311-2976
Mailing Address - Street 1:800 VIRGINIA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HAPEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30354-4302
Mailing Address - Country:US
Mailing Address - Phone:888-311-2976
Mailing Address - Fax:404-549-3393
Practice Address - Street 1:800 VIRGINIA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:HAPEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30354-4302
Practice Address - Country:US
Practice Address - Phone:888-311-2976
Practice Address - Fax:404-549-3393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-05
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care