Healthcare Provider Details

I. General information

NPI: 1316458847
Provider Name (Legal Business Name): VINCE PRIMO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22315 GOSLING RD
SPRING TX
77389-4409
US

IV. Provider business mailing address

22315 GOSLING RD
SPRING TX
77389-4409
US

V. Phone/Fax

Practice location:
  • Phone: 281-466-2618
  • Fax: 281-466-2893
Mailing address:
  • Phone: 281-466-2618
  • Fax: 281-466-2893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number3-20562-7504-6
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: