Healthcare Provider Details

I. General information

NPI: 1336626183
Provider Name (Legal Business Name): PREMIER GROUP HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2433 9TH AVE N
SAINT PETERSBURG FL
33713-6834
US

IV. Provider business mailing address

2433 9TH AVE N
SAINT PETERSBURG FL
33713-6834
US

V. Phone/Fax

Practice location:
  • Phone: 813-245-8416
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANGELA MACIVER
Title or Position: CEO
Credential:
Phone: 813-245-8416