Healthcare Provider Details

I. General information

NPI: 1912543026
Provider Name (Legal Business Name): PRIMAL HEALTH CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2019
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 HOPKINS LANDING DR
ESSEX MD
21221-2229
US

IV. Provider business mailing address

449 HOPKINS LANDING DR
ESSEX MD
21221-2229
US

V. Phone/Fax

Practice location:
  • Phone: 443-600-0181
  • Fax:
Mailing address:
  • Phone: 443-600-0181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JON KOGAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 443-253-5533