=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528502093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2016
-----------------------------------------------------
Last Update Date | 12/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 N WATER ST
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42420-3142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-212-1447
-----------------------------------------------------
Fax | 270-212-1388
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 N WATER ST
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42420-3142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-212-1447
-----------------------------------------------------
Fax | 270-212-1388
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JENNIFER L LILES
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 270-212-1447
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------