Healthcare Provider Details

I. General information

NPI: 1205204138
Provider Name (Legal Business Name): PREMIER INTEGRATED HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1554 UNION RD STE C
GASTONIA NC
28054-5581
US

IV. Provider business mailing address

1554 UNION RD STE C
GASTONIA NC
28054-5581
US

V. Phone/Fax

Practice location:
  • Phone: 704-678-8876
  • Fax:
Mailing address:
  • Phone: 704-678-8876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number001002367
License Number StateNC

VIII. Authorized Official

Name: WILLIAM CABANISS
Title or Position: OWNER
Credential: PA-C
Phone: 843-817-7077