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General NPI Number Information
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NPI Number | 1346604022
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Entity Type | Organization
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Legal Business Name | PROMESA PRIMARY CARE, LLC
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Dates
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Enumeration Date | 04/08/2016
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Last Update Date | 04/08/2016
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Provider Practice Location Address
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Address Line | 3978 BROCKTON AVE
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City | RIVERSIDE
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State | CA
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Zip | 92501-3203
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Country | US
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Telephone | 951-213-6505
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Fax | 951-213-6549
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Provider Business Mailing Address
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Address Line | 3978 BROCKTON AVE
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City | RIVERSIDE
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State | CA
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Zip | 92501-3203
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Country | US
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Telephone | 951-213-6505
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Fax | 951-213-6549
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | OMAR GOMEZ
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Credential |
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Telephone | 951-213-6505
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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