Provider Demographics
NPI:1871068726
Name:PRIMARY CARE PROVIDERS, LLC
Entity type:Organization
Organization Name:PRIMARY CARE PROVIDERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:CORINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:IANCULOVICI
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:732-292-0100
Mailing Address - Street 1:2640 HIGHWAY 70 BUILDING 6B
Mailing Address - Street 2:
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-2610
Mailing Address - Country:US
Mailing Address - Phone:732-292-0100
Mailing Address - Fax:732-292-0900
Practice Address - Street 1:2640 HWY 70, BLDG.5 SUITE 102B
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736
Practice Address - Country:US
Practice Address - Phone:732-292-0100
Practice Address - Fax:732-292-0900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-08
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty