Provider Demographics
NPI:1104060839
Name:PRIMARY MULTISPECIALTY CLINIC
Entity type:Organization
Organization Name:PRIMARY MULTISPECIALTY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATIENT RELATIONS COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:THERESE
Authorized Official - Middle Name:T
Authorized Official - Last Name:CHONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:671-688-1066
Mailing Address - Street 1:177 CHALAN PASAHERU # A
Mailing Address - Street 2:STE F
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-4161
Mailing Address - Country:US
Mailing Address - Phone:671-647-6201
Mailing Address - Fax:671-647-0045
Practice Address - Street 1:177 CHALAN PASAHERU STE C
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-4161
Practice Address - Country:US
Practice Address - Phone:671-647-6201
Practice Address - Fax:671-647-0045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GULEO 196261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty