Healthcare Provider Details

I. General information

NPI: 1487196150
Provider Name (Legal Business Name): PREMIER PEDIATRIC HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2016
Last Update Date: 11/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

287 GREEN OAK LN
MADISON MS
39110-8213
US

IV. Provider business mailing address

287 GREEN OAK LN
MADISON MS
39110-8213
US

V. Phone/Fax

Practice location:
  • Phone: 662-934-0206
  • Fax:
Mailing address:
  • Phone: 662-934-0206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: EMILY GRETCHEN HOLLOWAY
Title or Position: MEMBER
Credential: RN
Phone: 662-934-0206