Healthcare Provider Details

I. General information

NPI: 1437356276
Provider Name (Legal Business Name): PREMIUM MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 PALM AVE
HIALEAH FL
33010-4318
US

IV. Provider business mailing address

704 PALM AVE
HIALEAH FL
33010-4318
US

V. Phone/Fax

Practice location:
  • Phone: 305-863-6620
  • Fax: 305-863-6732
Mailing address:
  • Phone: 305-863-6620
  • Fax: 305-863-6732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number6181622
License Number StateFL

VIII. Authorized Official

Name: JUAN REYES
Title or Position: OWNER
Credential:
Phone: 305-863-6620