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General NPI Number Information
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NPI Number | 1801106620
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Entity Type | Organization
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Legal Business Name | PREMIERTOX, INC.
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Dates
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Enumeration Date | 10/14/2010
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Last Update Date | 10/27/2010
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Provider Practice Location Address
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Address Line | 2431 LAKEWAY DRIVE SUITE A1
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City | RUSSELL SPRINGS
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State | KY
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Zip | 42642
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Country | US
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Telephone | 270-866-3144
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1240
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City | RUSSELL SPRINGS
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State | KY
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Zip | 42642-1240
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Country | US
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Telephone | 270-866-3144
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRIAN WALTERS
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Credential |
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Telephone | 270-866-3144
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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