Healthcare Provider Details

I. General information

NPI: 1992903686
Provider Name (Legal Business Name): PREMIER ENT A MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 TERRACINA BLVD SUITE 201
REDLANDS CA
92373-4870
US

IV. Provider business mailing address

255 TERRACINA BLVD SUITE 201
REDLANDS CA
92373-4870
US

V. Phone/Fax

Practice location:
  • Phone: 909-793-2500
  • Fax: 951-845-2181
Mailing address:
  • Phone: 909-793-2500
  • Fax: 951-845-2181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA50970
License Number StateCA

VIII. Authorized Official

Name: SHAREN KNUDSEN JEFFRIES
Title or Position: OWNER
Credential: M.D.
Phone: 909-793-2500