Healthcare Provider Details

I. General information

NPI: 1871604934
Provider Name (Legal Business Name): PREMIEANT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 GANYMEDE LN
AUSTIN TX
78727
US

IV. Provider business mailing address

1110 W WILLIAM CANNON BLDG 2
AUSTIN TX
78745
US

V. Phone/Fax

Practice location:
  • Phone: 512-916-1632
  • Fax: 512-916-1639
Mailing address:
  • Phone: 512-916-1632
  • Fax: 512-916-1639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number7242
License Number StateTX

VIII. Authorized Official

Name: MR. DENNIS R LATIMER
Title or Position: CEO
Credential:
Phone: 512-916-1632