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General NPI Number Information
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NPI Number | 1679665921
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Entity Type | Organization
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Legal Business Name | PREMIER HEALTH CARE LLC
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Dates
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Enumeration Date | 09/28/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 111 13TH AVE NW
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City | ARDMORE
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State | OK
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Zip | 73401-5733
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Country | US
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Telephone | 580-223-4803
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Fax | 580-223-7781
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Provider Business Mailing Address
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Address Line | PO BOX 128
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City | ARDMORE
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State | OK
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Zip | 73402-0128
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Country | US
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Telephone | 580-490-9200
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Fax | 580-490-9201
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Authorized Official
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Title or Position | MEMBER/MANAGER
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Name | DR. GARY PORTER
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Credential | PH.D., J.D., D.PH.
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Telephone | 580-490-9200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | NH1002-1002
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License Number State | OK
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