1306452115 NPI number — PREMIER PAIN AND WELLNESS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306452115 NPI number — PREMIER PAIN AND WELLNESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER PAIN AND WELLNESS, 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:
1306452115
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9900 STIRLING RD
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33024-8043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-751-5588
Provider Business Mailing Address Fax Number:
954-751-5589

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9900 STIRLING RD
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33024-8043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-751-5588
Provider Business Practice Location Address Fax Number:
954-751-5589
Provider Enumeration Date:
09/17/2020

Additional Information

Authorized Official

Authorized Official Last Name:
RAMIREZ
Authorized Official First Name:
FELIX
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
305-316-5271

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 108187700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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