Healthcare Provider Details

I. General information

NPI: 1669193736
Provider Name (Legal Business Name): PREMISE HEALTH OF CALIFORNIA MEDICAL, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S CALIFORNIA ST
BURBANK CA
91505
US

IV. Provider business mailing address

5500 MARYLAND WAY
BRENTWOOD TN
37027-7048
US

V. Phone/Fax

Practice location:
  • Phone: 818-954-6900
  • Fax: 818-450-0840
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN LEIZMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 216-479-9063