1255313748 NPI number — PREMIER HOME CARE, INC.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255313748 NPI number — PREMIER HOME CARE, INC.

Employer Identification Number (EIN):

Provider Organization Name:

PREMIER HOME CARE, 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 Other Organization Name:

Provider Other Organization Name Type Code:

6

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:

1255313748

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

07/27/2022

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

3325 BARTLETT BLVD

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

ORLANDO

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

32811-6428

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

407-206-0040

Provider Business Mailing Address Fax Number:

407-206-0010

Provider First Line Business Practice Location Address:

2195 WATTERSON TRL

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

LOUISVILLE

Provider Business Practice Location Address State Name:

KY

Provider Business Practice Location Address Postal Code:

40299-2437

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

502-491-5243

Provider Business Practice Location Address Fax Number:

888-678-7190

Provider Enumeration Date:

11/18/2005

Authorized Official Last Name:

GRIGGS

Authorized Official First Name:

STEPHEN

Authorized Official Middle Name:

P

Authorized Official Title or Position:

CEO / PRESIDENT

Authorized Official Telephone Number:

407-206-0040

• Taxonomy code: 332B00000X , with the licence number:  199493 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 332BX2000X , with the licence number: 909286 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 7100035240 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
• Identifier: MG0332 . This is a "KENTUCKY BOARD OF PHARMACY LICENSE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 389449P . This is a "SIHO" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
• Identifier: 1074015 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
• Identifier: 200147650 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 91022 . This is a "APB" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 400030 . This is a "BLACK LUNG" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 45909991 . This is a "EPSDT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 80341 . This is a "NORTHWOOD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 000000069783 . This is a "ANTHEM ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".