Healthcare Provider Details

I. General information

NPI: 1174858153
Provider Name (Legal Business Name): PRIM HEALTH SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2009
Last Update Date: 10/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 WILSHIRE BLVD SUITE 603
LOS ANGELES CA
90036-4303
US

IV. Provider business mailing address

1317 N SAN FERNANDO BLVD 301
BURBANK CA
91504-4236
US

V. Phone/Fax

Practice location:
  • Phone: 213-995-5054
  • Fax: 213-652-1908
Mailing address:
  • Phone: 213-995-5054
  • Fax: 213-652-1908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA72562
License Number StateCA

VIII. Authorized Official

Name: STEPHEN D MABERRY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 213-995-5054