=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962680397
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIUM NURSING SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2008
-----------------------------------------------------
Last Update Date | 08/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4118 WELLINGTON HILLS LN
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30039-4225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-438-0813
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4118 WELLINGTON HILLS LN
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30039-4225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-573-7121
-----------------------------------------------------
Fax | 678-935-1990
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BRANCH MANAGER
-----------------------------------------------------
Name | MS. SHIRLEY RENEE CATLEDGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-438-0813
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 067-R-0343
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------