Basic Information
| Provider Information | |||||||||
| NPI: | 1154785517 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENT PRIMARY CARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3349 G ST STE C | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953400978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093844400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3349 G ST STE C | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953400978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095804638 | ||||||||
| FaxNumber: | 2095804163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2016 | ||||||||
| LastUpdateDate: | 10/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | TIU | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2093844400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 363LP2300X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.