Provider Demographics
NPI:1629749783
Name:PRIME GROUP MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:PRIME GROUP MEDICAL CLINIC LLC
Other - Org Name:PRIME GROUP MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-438-4493
Mailing Address - Street 1:3224 I 30 STE 148
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-2693
Mailing Address - Country:US
Mailing Address - Phone:469-438-4493
Mailing Address - Fax:
Practice Address - Street 1:3224 I 30 STE 148
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-2693
Practice Address - Country:US
Practice Address - Phone:469-438-4493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-27
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty