MEDICARE: PREMIUM ADVISORS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1831870617
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIUM ADVISORS

Provider Business Mailing Address
First Line	:	6314 SOUTH 54TH LANE, LAVEEN VILLAGE, AZ, USA
Second Line	:
City	:	LAVEEN
State	:	AZ
Zip	:	85339
Country	:	US
Telephone Number	:	602-317-1006
Fax Number	:

Provider Business Practice Location Address
First Line	:	6314 SOUTH 54TH LANE, LAVEEN VILLAGE, AZ, USA
Second Line	:
City	:	LAVEEN
State	:	AZ
Zip	:	85339
Country	:	US
Telephone Number	:	602-317-1006
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DESTINY CARTER
Credential	:
Telephone Number	:	602-317-1006

Provider Enumeration Date	:	07/26/2023
Last Update Date	:	07/26/2023

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