1588299317 NPI number — PREMIER KIDS CARE, INC.

Table of content: (NPI 1588299317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588299317 NPI number — PREMIER KIDS CARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER KIDS 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:
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:
1588299317
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
221 PLAZA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30655-3184
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-207-9001
Provider Business Mailing Address Fax Number:
866-810-4021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
312 N NEW WARRINGTON RD STE 4B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32506-5855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-892-9001
Provider Business Practice Location Address Fax Number:
866-810-4021
Provider Enumeration Date:
03/12/2020

Additional Information

Authorized Official

Authorized Official Last Name:
LEICHT
Authorized Official First Name:
CHELLA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CONTRACTING
Authorized Official Telephone Number:
888-892-9001

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 109194000 . 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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