=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063227528
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER HOME CARE 1 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2025
-----------------------------------------------------
Last Update Date | 07/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 S 1ST ST
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72756-4670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-851-4334
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6736 N 129TH EAST AVE
-----------------------------------------------------
City | OWASSO
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74055-7160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-851-4334
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAKOTA JAMES PRUITT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-851-4334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------