Healthcare Provider Details

I. General information

NPI: 1669204012
Provider Name (Legal Business Name): PREMIER HEALTHCARE SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2024
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1892 TURNPIKE RD
RAEFORD NC
28376-8520
US

IV. Provider business mailing address

2990 SUNNYSIDE SCHOOL RD
FAYETTEVILLE NC
28312-6914
US

V. Phone/Fax

Practice location:
  • Phone: 877-472-2302
  • Fax: 877-472-2302
Mailing address:
  • Phone: 850-512-9166
  • Fax: 877-472-2302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: FRED DOUGLAS SURGEON
Title or Position: CEO
Credential:
Phone: 910-733-0617