Healthcare Provider Details

I. General information

NPI: 1700207842
Provider Name (Legal Business Name): PRIME HEALTHCARE SERVICES LANDMARK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2013
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 CASS AVE
WOONSOCKET RI
02895-4736
US

IV. Provider business mailing address

219 CASS AVE
WOONSOCKET RI
02895-4736
US

V. Phone/Fax

Practice location:
  • Phone: 401-769-4100
  • Fax: 401-766-9575
Mailing address:
  • Phone: 401-769-4100
  • Fax: 401-766-9575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. STACY VIENS
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 401-769-4100