Healthcare Provider Details

I. General information

NPI: 1750204277
Provider Name (Legal Business Name): PREMIUM RESIDENTIAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 MAPLE AVE
IRVINGTON NJ
07111-4322
US

IV. Provider business mailing address

6 TREEMAN DR UNIT 302
HILLSBOROUGH NJ
08844-4795
US

V. Phone/Fax

Practice location:
  • Phone: 347-742-5642
  • Fax:
Mailing address:
  • Phone: 347-742-5642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. LESLIE MARTINEZ
Title or Position: MANAGING MEMBER
Credential:
Phone: 347-742-5642