Healthcare Provider Details

I. General information

NPI: 1487481487
Provider Name (Legal Business Name): PREMISE HEALTH OF TEXAS MEDICAL, P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 FM 119 STE 170
SUNRAY TX
79086-2013
US

IV. Provider business mailing address

5500 MARYLAND WAY STE 120
BRENTWOOD TN
37027-4993
US

V. Phone/Fax

Practice location:
  • Phone: 806-935-1503
  • Fax: 806-935-1429
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN B LEIZMAN
Title or Position: PRESIDENT
Credential:
Phone: 615-468-6270