Healthcare Provider Details

I. General information

NPI: 1730870163
Provider Name (Legal Business Name): PREMIER CARE OF OHIO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 BROOKPARK RD
CLEVELAND OH
44129-1219
US

IV. Provider business mailing address

8444 N 90TH ST STE 100
SCOTTSDALE AZ
85258-4437
US

V. Phone/Fax

Practice location:
  • Phone: 440-672-6955
  • Fax: 216-331-1175
Mailing address:
  • Phone: 804-942-4974
  • Fax: 480-687-7361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ALEX G VILCHIS
Title or Position: CREDENTIALING PROVIDER DATA MANAGER
Credential:
Phone: 602-248-8886