1134760002 NPI number — PREMIEANT INC

Table of content: (NPI 1134760002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134760002 NPI number — PREMIEANT INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIEANT INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
REGENCY COVE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134760002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1110 W WILLIAM CANNON DR BLDG 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78745-5468
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-916-1632
Provider Business Mailing Address Fax Number:
512-916-1639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6402 REGENCY CV
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78249-4844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-916-1632
Provider Business Practice Location Address Fax Number:
512-916-1639
Provider Enumeration Date:
10/02/2019

Additional Information

Authorized Official

Authorized Official Last Name:
ENGELKE
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
512-916-1632

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1467563536 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1871604934 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396856514 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1962505321 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1871696237 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1144323502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1235232695 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1124139340 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1326141789 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1407967573 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1235240300 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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