MEDICARE: CORE PRIMARYCARE CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
2	363LG0600X	Gerontology Nurse Practitioner

General Provider Information

NPI Number	:	1568221885
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORE PRIMARYCARE CLINIC LLC

Provider Business Mailing Address
First Line	:	6500 NORTHWEST DR STE 350
Second Line	:
City	:	MESQUITE
State	:	TX
Zip	:	75150-1364
Country	:	US
Telephone Number	:	575-571-6946
Fax Number	:

Provider Business Practice Location Address
First Line	:	1557 MONTE VISTA AVE
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-5731
Country	:	US
Telephone Number	:	575-571-6946
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EKEOMA I COOPER
Credential	:	MD
Telephone Number	:	575-571-6946

Provider Enumeration Date	:	03/18/2024
Last Update Date	:	07/30/2024

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