Provider Demographics
NPI:1871062307
Name:ADVANTAGE PRIMARY CARE, PLLC
Entity type:Organization
Organization Name:ADVANTAGE PRIMARY CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, DNP, FNP-BC
Authorized Official - Phone:352-484-0422
Mailing Address - Street 1:20212 E PENNSYLVANIA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34432-6032
Mailing Address - Country:US
Mailing Address - Phone:352-484-0422
Mailing Address - Fax:352-484-1430
Practice Address - Street 1:20212 E PENNSYLVANIA AVE STE B
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34432-6032
Practice Address - Country:US
Practice Address - Phone:352-484-0422
Practice Address - Fax:352-484-1430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty