1255578803 NPI number — PREMIUM LIFE CARE, INC.,

Table of content: (NPI 1255578803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255578803 NPI number — PREMIUM LIFE CARE, INC.,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIUM LIFE 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's Other Name Information

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 Information

NPI Number:
1255578803
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3220 S HIGUERA ST
Provider Second Line Business Mailing Address:
SUITE 315
Provider Business Mailing Address City Name:
SAN LUIS OBISPO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93401-6987
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-548-8811
Provider Business Mailing Address Fax Number:
805-715-3460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3220 S HIGUERA ST
Provider Second Line Business Practice Location Address:
SUITE 315
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93401-6987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-548-8811
Provider Business Practice Location Address Fax Number:
805-242-0676
Provider Enumeration Date:
01/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
VIEIRA
Authorized Official First Name:
MECHELL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
805-548-8811

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 550003349 . This is a "STATE HOME HEALTH AGENCY LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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