Provider Demographics
NPI:1881629384
Name:PRIME CARE FAMILY PRACTICE, P.C.
Entity Type:Organization
Organization Name:PRIME CARE FAMILY PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEIDRA
Authorized Official - Middle Name:F
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-526-1111
Mailing Address - Street 1:4700 PUDDLEDOCK ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PRINCE GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23875-1268
Mailing Address - Country:US
Mailing Address - Phone:804-526-1111
Mailing Address - Fax:804-526-8363
Practice Address - Street 1:4700 PUDDLEDOCK ROAD
Practice Address - Street 2:SUITE 300
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-1268
Practice Address - Country:US
Practice Address - Phone:804-526-1111
Practice Address - Fax:804-526-8363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C03704Medicare PIN