Provider Demographics
NPI:1629566203
Name:PRIORITY CARE PROVIDER, LLC
Entity Type:Organization
Organization Name:PRIORITY CARE PROVIDER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:NIMCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:267-254-4553
Mailing Address - Street 1:425 LAWRENCE RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19006-2334
Mailing Address - Country:US
Mailing Address - Phone:267-254-4553
Mailing Address - Fax:
Practice Address - Street 1:1000 GUM PL APT A
Practice Address - Street 2:
Practice Address - City:HUNTINGDON VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19006-1716
Practice Address - Country:US
Practice Address - Phone:267-254-4553
Practice Address - Fax:215-893-5231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-29
Last Update Date:2018-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACER-00125254251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health