Healthcare Provider Details

I. General information

NPI: 1952571234
Provider Name (Legal Business Name): PREMIER LIFE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 ADDISON AVE E
TWIN FALLS ID
83301-5343
US

IV. Provider business mailing address

1625 ADDISON AVE E
TWIN FALLS ID
83301-5343
US

V. Phone/Fax

Practice location:
  • Phone: 208-735-2442
  • Fax: 208-735-9030
Mailing address:
  • Phone: 208-735-2442
  • Fax: 208-735-9030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberCHIA-754
License Number StateID

VIII. Authorized Official

Name: LORAINE M GUMPER
Title or Position: OWNER
Credential: DC
Phone: 208-735-2442