Provider Demographics
NPI:1760034300
Name:PRIMARY CARE 369 LLC
Entity Type:Organization
Organization Name:PRIMARY CARE 369 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAYATRI
Authorized Official - Middle Name:
Authorized Official - Last Name:SIRAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-315-0198
Mailing Address - Street 1:8990 LAKEVIEW PL
Mailing Address - Street 2:
Mailing Address - City:PARKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33076-4122
Mailing Address - Country:US
Mailing Address - Phone:954-801-5172
Mailing Address - Fax:
Practice Address - Street 1:9980 CENTRAL PARK BLVD N STE 314
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-1704
Practice Address - Country:US
Practice Address - Phone:561-315-0198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-14
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care