Healthcare Provider Details

I. General information

NPI: 1659846293
Provider Name (Legal Business Name): PREMIER SPORTS MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35670 KENAI SPUR HWY STE 104
SOLDOTNA AK
99669-7649
US

IV. Provider business mailing address

35670 KENAI SPUR HWY STE 104
SOLDOTNA AK
99669-7649
US

V. Phone/Fax

Practice location:
  • Phone: 907-262-0801
  • Fax: 907-262-0860
Mailing address:
  • Phone: 907-262-0801
  • Fax: 907-262-0860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHERYL KAY LARSON
Title or Position: OWNER/OFFICE MANAGER
Credential:
Phone: 907-262-0801