Healthcare Provider Details

I. General information

NPI: 1467082396
Provider Name (Legal Business Name): PREMIER SERVICE OF CAROLINA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2020
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 W KING ST
KINGS MOUNTAIN NC
28086-3310
US

IV. Provider business mailing address

929 CONCORD PKWY S STE K
CONCORD NC
28027-5031
US

V. Phone/Fax

Practice location:
  • Phone: 704-750-4222
  • Fax:
Mailing address:
  • Phone: 704-985-1189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: WARNER LEAK
Title or Position: OWNER, CEO
Credential:
Phone: 704-985-1189