Healthcare Provider Details

I. General information

NPI: 1467103382
Provider Name (Legal Business Name): PREMIER HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 SE OLSON DR
WAUKEE IA
50263-8641
US

IV. Provider business mailing address

890 SE OLSON DR
WAUKEE IA
50263-8641
US

V. Phone/Fax

Practice location:
  • Phone: 515-325-8739
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KYLAR MCCANN
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 641-223-3418