Healthcare Provider Details

I. General information

NPI: 1164912853
Provider Name (Legal Business Name): PREMIER THERAPEUTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 W 22ND AVE
COVINGTON LA
70433-1433
US

IV. Provider business mailing address

222 N VERMONT ST STE S
COVINGTON LA
70433-3240
US

V. Phone/Fax

Practice location:
  • Phone: 985-377-6983
  • Fax:
Mailing address:
  • Phone: 985-377-6983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLA-4964
License Number StateLA

VIII. Authorized Official

Name: MR. KEVIN J BROWN
Title or Position: OWNER
Credential: LMT
Phone: 985-377-6983