Healthcare Provider Details

I. General information

NPI: 1255928750
Provider Name (Legal Business Name): PREMIUM PERSONAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2020
Last Update Date: 12/30/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1639 W NORTH BEND RD
CINCINNATI OH
45224-2023
US

IV. Provider business mailing address

1639 W NORTH BEND RD
CINCINNATI OH
45224-2023
US

V. Phone/Fax

Practice location:
  • Phone: 513-967-1056
  • Fax:
Mailing address:
  • Phone: 513-967-1056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MICHELLE CAROL JOHNSON
Title or Position: CEO
Credential: M.ED
Phone: 513-967-1056