Healthcare Provider Details

I. General information

NPI: 1477109528
Provider Name (Legal Business Name): PREMIER MEDICAL MOVEMENT MANAGEMENT COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2019
Last Update Date: 08/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26000 HOOVER RD
WARREN MI
48089-1167
US

IV. Provider business mailing address

529 N GULLEY RD
DEARBORN HTS MI
48127-3453
US

V. Phone/Fax

Practice location:
  • Phone: 586-434-5260
  • Fax: 586-434-5261
Mailing address:
  • Phone: 313-207-5767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ABLA M SOUEIDAN
Title or Position: OWNER
Credential:
Phone: 313-207-5767