1265860795 NPI number — PREMIUN HEALTH CARE ASSOCIATES

Table of content: (NPI 1265860795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265860795 NPI number — PREMIUN HEALTH CARE ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIUN HEALTH CARE ASSOCIATES
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:
1265860795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1519 AVE PONCE DE LEON
Provider Second Line Business Mailing Address:
SUITE 1201
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00910-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-562-5168
Provider Business Mailing Address Fax Number:
787-722-2371

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1519 AVE PONCE DE LEON
Provider Second Line Business Practice Location Address:
SUITE 1201
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00910-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-562-5168
Provider Business Practice Location Address Fax Number:
787-722-2371
Provider Enumeration Date:
10/18/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LOPEZ
Authorized Official First Name:
YAMILET
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-562-5168

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  331348 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 331348 . This is a "LLC" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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