Provider Demographics
NPI:1265120174
Name:FAITHFUL PRIMARY CARE LLC
Entity type:Organization
Organization Name:FAITHFUL PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:941-292-0123
Mailing Address - Street 1:12161 MERCADO DR # 123
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-1147
Mailing Address - Country:US
Mailing Address - Phone:941-292-0123
Mailing Address - Fax:
Practice Address - Street 1:200 TAMIAMI TRL N STE A
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-1914
Practice Address - Country:US
Practice Address - Phone:941-292-0123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-27
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty