Healthcare Provider Details

I. General information

NPI: 1427953504
Provider Name (Legal Business Name): PRIME CHOICE & CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11707 TETRAFIN DR
RIVERVIEW FL
33579-4127
US

IV. Provider business mailing address

11707 TETRAFIN DR
RIVERVIEW FL
33579-4127
US

V. Phone/Fax

Practice location:
  • Phone: 863-844-1735
  • Fax:
Mailing address:
  • Phone: 863-844-1735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: CARISSA RANDALL WALLACE
Title or Position: OWNER
Credential:
Phone: 863-844-1735