Healthcare Provider Details

I. General information

NPI: 1558102228
Provider Name (Legal Business Name): PREMIER FAMILY HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N PROGRESS AVE
SILOAM SPRINGS AR
72761-4093
US

IV. Provider business mailing address

11005 N WEDINGTON BLACKTOP RD
LINCOLN AR
72744-9459
US

V. Phone/Fax

Practice location:
  • Phone: 479-225-5429
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TRACEY MOORE
Title or Position: MEMBER
Credential:
Phone: 479-225-5429