Healthcare Provider Details

I. General information

NPI: 1447699178
Provider Name (Legal Business Name): PRIME ASSURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2013
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 WINTER LN
TALLAHASSEE FL
32311-1267
US

IV. Provider business mailing address

1060 WINTER LN
TALLAHASSEE FL
32311-1267
US

V. Phone/Fax

Practice location:
  • Phone: 850-524-1577
  • Fax:
Mailing address:
  • Phone: 850-852-4157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number2721822
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number2721822
License Number StateFL

VIII. Authorized Official

Name: DR. ULOMA D ONUBOGU
Title or Position: MANAGER
Credential: PHD., ARNP
Phone: 85085241577