Healthcare Provider Details

I. General information

NPI: 1942051511
Provider Name (Legal Business Name): PREMIUM HEALTH PROFESSIONALS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 04/01/2024
Certification Date: 03/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 MEDIANOCHE ST
LAS VEGAS NV
89138-6364
US

IV. Provider business mailing address

211 MEDIANOCHE ST
LAS VEGAS NV
89138-6364
US

V. Phone/Fax

Practice location:
  • Phone: 646-491-3035
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080B0002X
TaxonomyPediatric Obesity Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. PEACE IBEKWE
Title or Position: OWNER
Credential: MD
Phone: 646-491-3035