Healthcare Provider Details

I. General information

NPI: 1659378057
Provider Name (Legal Business Name): PREMI THOMAS ME
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 BEVERLY BLVD ROOM 8725
WEST HOLLYWOOD CA
90048-1804
US

IV. Provider business mailing address

31255 CEDAR VALLEY DR SUITE 324
WESTLAKE VILLAGE CA
91362-4014
US

V. Phone/Fax

Practice location:
  • Phone: 818-338-8103
  • Fax: 818-338-8119
Mailing address:
  • Phone: 818-338-8103
  • Fax: 818-338-8119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA38948
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: