Healthcare Provider Details

I. General information

NPI: 1083157440
Provider Name (Legal Business Name): PREMIERCARE @HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2016
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 N WESTBERRY ST
SYLVESTER GA
31791-2125
US

IV. Provider business mailing address

302 N WESTBERRY ST
SYLVESTER GA
31791-2125
US

V. Phone/Fax

Practice location:
  • Phone: 229-288-2638
  • Fax:
Mailing address:
  • Phone: 229-288-2638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number159-R-1694
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. GWENDOLYN MCDANIEL
Title or Position: OWNERD
Credential:
Phone: 229-288-2638