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General NPI Number Information
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NPI Number | 1417350828
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Entity Type | Organization
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Legal Business Name | PREMIUM SELECT
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Dates
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Enumeration Date | 09/30/2014
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Last Update Date | 09/30/2014
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Provider Practice Location Address
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Address Line | 4303 F ST SE
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City | WASHINGTON
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State | DC
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Zip | 20019-4253
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Country | US
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Telephone | 202-718-0504
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Fax |
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Provider Business Mailing Address
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Address Line | 4303 F ST SE
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City | WASHINGTON
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State | DC
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Zip | 20019-4253
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Country | US
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Telephone | 202-718-0504
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Fax |
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Authorized Official
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Title or Position | HHA
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Name | MS. SANDRA MARIE SEAWELL
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Credential |
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Telephone | 202-718-0504
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | HHA5982
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License Number State | DC
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