Provider Demographics
NPI:1790331759
Name:PRIME MEDICAL HEALTH AND WELLNESS LLC
Entity Type:Organization
Organization Name:PRIME MEDICAL HEALTH AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-759-9819
Mailing Address - Street 1:24301 WALDEN CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4965
Mailing Address - Country:US
Mailing Address - Phone:239-345-8001
Mailing Address - Fax:239-345-8003
Practice Address - Street 1:24301 WALDEN CENTER DR STE 300
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4965
Practice Address - Country:US
Practice Address - Phone:239-345-8001
Practice Address - Fax:239-345-8003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-15
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1699092627Medicaid