Healthcare Provider Details

I. General information

NPI: 1205134970
Provider Name (Legal Business Name): PRIME CARE MEDICAL MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2011
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1914 NW 84TH AVE
DORAL FL
33126-1030
US

IV. Provider business mailing address

1914 NW 84TH AVE
DORAL FL
33126-1030
US

V. Phone/Fax

Practice location:
  • Phone: 305-363-3675
  • Fax: 305-442-2207
Mailing address:
  • Phone: 305-363-3675
  • Fax: 305-442-2207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NERELYS PEREZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 305-442-1740