=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518570860
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIME CARE CONSULTANTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2020
-----------------------------------------------------
Last Update Date | 12/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3707 VIRGINIA BEACH BLVD STE 202
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23452-3412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-453-1180
-----------------------------------------------------
Fax | 757-453-1187
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3707 VIRGINIA BEACH BLVD STE 202
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23452-3412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-453-1180
-----------------------------------------------------
Fax | 757-453-1187
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. JOHN L WALLACE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-453-1180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------