Provider Demographics
NPI:1649885559
Name:PRIMARY CARE 360
Entity type:Organization
Organization Name:PRIMARY CARE 360
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KHALID
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-393-5050
Mailing Address - Street 1:21117 ARCH ST
Mailing Address - Street 2:
Mailing Address - City:HENSLEY
Mailing Address - State:AR
Mailing Address - Zip Code:72065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21117 ARCH ST
Practice Address - Street 2:
Practice Address - City:HENSLEY
Practice Address - State:AR
Practice Address - Zip Code:72065
Practice Address - Country:US
Practice Address - Phone:870-393-5050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMARY CARE 360
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-09
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty