Healthcare Provider Details

I. General information

NPI: 1477995231
Provider Name (Legal Business Name): PREMIUM CARE MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3570 HOLIDAY DR SUITES 3-7
NEW ORLEANS LA
70114-8287
US

IV. Provider business mailing address

3570 HOLIDAY DR SUITES 3-7
NEW ORLEANS LA
70114-8287
US

V. Phone/Fax

Practice location:
  • Phone: 504-361-4203
  • Fax: 504-361-4204
Mailing address:
  • Phone: 504-361-4203
  • Fax: 504-361-4204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: PRINCESS DENNAR
Title or Position: CEO/MANAGING PARTNER
Credential: MD
Phone: 504-361-4203