Provider Demographics
NPI:1427447143
Name:AT HOME PRIMARY CARE LLC.
Entity type:Organization
Organization Name:AT HOME PRIMARY CARE LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUZIE
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-344-6717
Mailing Address - Street 1:6400 SE LAKE RD # 420
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2129
Mailing Address - Country:US
Mailing Address - Phone:503-344-6717
Mailing Address - Fax:
Practice Address - Street 1:6400 SE LAKE RD # 420
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97222-2129
Practice Address - Country:US
Practice Address - Phone:503-344-6717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-19
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty