Healthcare Provider Details

I. General information

NPI: 1679889968
Provider Name (Legal Business Name): PREMIER FAMILY AND PALLIATIVE MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W SAMPLE RD # 3104
POMPANO BEACH FL
33064-3547
US

IV. Provider business mailing address

1 W SAMPLE RD SUITE 104
POMPANO BEACH FL
33064-3547
US

V. Phone/Fax

Practice location:
  • Phone: 954-782-2802
  • Fax:
Mailing address:
  • Phone: 954-782-2802
  • Fax: 954-782-2881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS10256
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberOS10256
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberOS10256
License Number StateFL

VIII. Authorized Official

Name: LAURA BURKE
Title or Position: MCC
Credential:
Phone: 954-782-2802