Healthcare Provider Details

I. General information

NPI: 1790239762
Provider Name (Legal Business Name): PREMIER MEDICAL CNTR OF HUMACAO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE. BOULEVARD SUR, TORRE PISO 1 BOULEVARD DEL RIO OFFICE CENTER, BO. RIO ABAJO
HUMACAO PR
00791-0000
US

IV. Provider business mailing address

10319 JEFFERSON HWY
BATON ROUGE LA
70809-2730
US

V. Phone/Fax

Practice location:
  • Phone: 787-656-2727
  • Fax: 787-656-2732
Mailing address:
  • Phone: 225-214-9352
  • Fax: 225-214-9349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. TAMARA B WHITE
Title or Position: VP, REV. CYCLE SERVICES
Credential:
Phone: 225-239-7190