Healthcare Provider Details

I. General information

NPI: 1366584849
Provider Name (Legal Business Name): PREMIUM HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 B N. CRUTCHFIELD ST.
DOBSON NC
27017-0265
US

IV. Provider business mailing address

PO BOX 265
DOBSON NC
27017-0265
US

V. Phone/Fax

Practice location:
  • Phone: 336-386-9777
  • Fax: 336-386-9775
Mailing address:
  • Phone: 336-386-9777
  • Fax: 336-386-9775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHC3356
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3418125
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
Identifier6601459
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MS. TERESA S. HARRISON
Title or Position: DIRECTOR
Credential: OWNER
Phone: 336-386-9777