Healthcare Provider Details

I. General information

NPI: 1013843861
Provider Name (Legal Business Name): PRIME VIRTUAL CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4539 N 22ND ST STE R
PHOENIX AZ
85016-4639
US

IV. Provider business mailing address

165 ITHACA ST
BAY SHORE NY
11706-4606
US

V. Phone/Fax

Practice location:
  • Phone: 520-843-4567
  • Fax:
Mailing address:
  • Phone: 520-843-4567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SMITH JACKSON
Title or Position: MANAGER
Credential:
Phone: 520-843-4567