Provider Demographics
NPI:1841937893
Name:PRIME MINDED CARE
Entity type:Organization
Organization Name:PRIME MINDED CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALIMATA
Authorized Official - Middle Name:
Authorized Official - Last Name:SORE OUEDRAOGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-235-5484
Mailing Address - Street 1:46-48 CRAWFORD ST APT 3
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-1157
Mailing Address - Country:US
Mailing Address - Phone:216-235-5484
Mailing Address - Fax:
Practice Address - Street 1:46-48 CRAWFORD ST APT 3
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1157
Practice Address - Country:US
Practice Address - Phone:216-235-5484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJS65780240061822OtherDRIVING LICENSE