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General NPI Number Information
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NPI Number | 1417180043
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Entity Type | Organization
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Legal Business Name | PREMIER LIFE HEALTH SERVICES, LLC
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Dates
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Enumeration Date | 08/31/2009
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Last Update Date | 09/24/2009
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Provider Practice Location Address
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Address Line | 4737 OLD CANOE CREEK ROAD
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City | SAINT CLOUD
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State | FL
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Zip | 34769-0000
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Country | US
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Telephone | 407-892-3627
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Fax | 407-892-3625
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Provider Business Mailing Address
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Address Line | PO BOX 702382
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City | SAINT CLOUD
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State | FL
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Zip | 34770-2382
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Country | US
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Telephone | 407-892-3627
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Fax | 407-892-3625
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KETTY MAURICE
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Credential | D.O.
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Telephone | 407-892-3627
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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