Provider Demographics
NPI:1699307751
Name:PRIDE COMPREHENSIVE PRIMARY CARE LLC
Entity type:Organization
Organization Name:PRIDE COMPREHENSIVE PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JURG
Authorized Official - Middle Name:W J
Authorized Official - Last Name:OGGENFUSS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-BC, ANP-BC
Authorized Official - Phone:414-614-5832
Mailing Address - Street 1:7 WARREN RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-3015
Mailing Address - Country:US
Mailing Address - Phone:414-614-5832
Mailing Address - Fax:
Practice Address - Street 1:7 WARREN RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-3015
Practice Address - Country:US
Practice Address - Phone:414-614-5832
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care