Provider Demographics
NPI:1427691625
Name:PRIM, ABIGAIL
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:PRIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1284 W MARQUETTE WOODS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9717
Mailing Address - Country:US
Mailing Address - Phone:219-575-8192
Mailing Address - Fax:
Practice Address - Street 1:4032 M 139
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8665
Practice Address - Country:US
Practice Address - Phone:269-556-1256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care