Healthcare Provider Details

I. General information

NPI: 1154945913
Provider Name (Legal Business Name): PRIMERA WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2020
Last Update Date: 06/07/2020
Certification Date: 06/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 BABCOCK RD STE 238-2
SAN ANTONIO TX
78229-4708
US

IV. Provider business mailing address

6956 INDIANA AVE STE 5
RIVERSIDE CA
92506-4109
US

V. Phone/Fax

Practice location:
  • Phone: 210-563-3779
  • Fax: 951-462-1161
Mailing address:
  • Phone: 951-423-2202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: JODI BENNETT
Title or Position: ADMINISTRATOR
Credential:
Phone: 951-423-2202