1376640508 NPI number — PREMIUM HEALTH, CORP.

Table of content: DR. RILEY LOUIS SMITH DO (NPI 1235821059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376640508 NPI number — PREMIUM HEALTH, CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIUM HEALTH, CORP.
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:
Provider Other Organization Name Type Code:
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:
1376640508
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1747 VAN BUREN ST
Provider Second Line Business Mailing Address:
925
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33020-5131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-922-1330
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1747 VAN BUREN ST
Provider Second Line Business Practice Location Address:
925
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33020-5131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-922-1330
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LEON
Authorized Official First Name:
JULISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
954-922-1330

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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