MEDICARE: PRIME VIRTUAL CARE CENTER 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1942135454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME VIRTUAL CARE CENTER LLC

Provider Business Mailing Address
First Line	:	165 ITHACA ST
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-4606
Country	:	US
Telephone Number	:	520-843-4567
Fax Number	:

Provider Business Practice Location Address
First Line	:	165 ITHACA ST
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-4606
Country	:	US
Telephone Number	:	520-843-4567
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	SMITH JACKSON
Credential	:
Telephone Number	:	520-843-4567

Provider Enumeration Date	:	06/16/2026
Last Update Date	:	06/16/2026

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