1578908869 NPI number — PREMIERTOX 2.0 INC.

Table of content: (NPI 1578908869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578908869 NPI number — PREMIERTOX 2.0 INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIERTOX 2.0 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:
1578908869
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 538512
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30353-8512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-226-3858
Provider Business Mailing Address Fax Number:
502-223-9829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7333 BARLITE BLVD
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78224-1320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-272-0010
Provider Business Practice Location Address Fax Number:
210-272-0153
Provider Enumeration Date:
05/01/2013

Additional Information

Authorized Official

Authorized Official Last Name:
KLIPP
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
270-866-8854

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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