Healthcare Provider Details

I. General information

NPI: 1225548860
Provider Name (Legal Business Name): PREMIER 1 HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2017
Last Update Date: 10/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 E 5TH ST N
BIG STONE GAP VA
24219-2435
US

IV. Provider business mailing address

928 E 5TH ST N
BIG STONE GAP VA
24219-2435
US

V. Phone/Fax

Practice location:
  • Phone: 276-524-1906
  • Fax: 276-524-1908
Mailing address:
  • Phone: 276-524-1906
  • Fax: 276-524-1908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: SPENCER KELLY BOWMAN
Title or Position: CEO
Credential:
Phone: 276-524-1906