Healthcare Provider Details

I. General information

NPI: 1538809819
Provider Name (Legal Business Name): PREMISE HEALTH OF CALIFORNIA MEDICAL, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 PRAIRIE CITY RD # FM7-95
FOLSOM CA
95630-9501
US

IV. Provider business mailing address

5500 MARYLAND WAY STE 120
BRENTWOOD TN
37027-4993
US

V. Phone/Fax

Practice location:
  • Phone: 916-377-9909
  • Fax: 916-357-7773
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

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