Healthcare Provider Details

I. General information

NPI: 1871280941
Provider Name (Legal Business Name): PRIME CARE TRANSFORMATION ORGANIZATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9649 BELAIR RD STE 202
BALTIMORE MD
21236-1116
US

IV. Provider business mailing address

9649 BELAIR RD STE 202
BALTIMORE MD
21236-1116
US

V. Phone/Fax

Practice location:
  • Phone: 410-237-6904
  • Fax: 410-237-6912
Mailing address:
  • Phone: 410-237-6904
  • Fax: 410-237-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CHAUNTE FRANCINE HARRIS
Title or Position: EXECUTIVE DIRECTOR
Credential: PHARMD
Phone: 410-237-6904