=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710695101
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMAL POINT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2022
-----------------------------------------------------
Last Update Date | 11/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8713 HARFORD RD STE 102
-----------------------------------------------------
City | PARKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21234-4650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-870-1590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8713 HARFORD RD STE 102
-----------------------------------------------------
City | PARKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21234-4650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-870-1590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NGUFOR FUBE DIVINE
-----------------------------------------------------
Credential | PMHNP
-----------------------------------------------------
Telephone | 410-870-1590
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------