1386694479 NPI number — PREMIERE OXYGEN, LLC

Table of content: (NPI 1386694479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386694479 NPI number — PREMIERE OXYGEN, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIERE OXYGEN, LLC
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:
1386694479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3107 N DEER RUN RD
Provider Second Line Business Mailing Address:
STE. 14
Provider Business Mailing Address City Name:
CARSON CITY
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-883-2004
Provider Business Mailing Address Fax Number:
775-884-4550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3107 N DEER RUN RD
Provider Second Line Business Practice Location Address:
STE. 14
Provider Business Practice Location Address City Name:
CARSON CITY
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89701-2406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-883-2004
Provider Business Practice Location Address Fax Number:
775-884-4550
Provider Enumeration Date:
05/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WENDELL
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
K
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
775-883-2004

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  MP00369 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100509520 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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