MEDICARE: PREMIEANT INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility	3695	TX

General Provider Information

NPI Number	:	1396856514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIEANT INC

Provider Business Mailing Address
First Line	:	1110 WEST WILLIAM CANNON
Second Line	:	BUILDING 2
City	:	AUSTIN
State	:	TX
Zip	:	78745
Country	:	US
Telephone Number	:	512-916-1632
Fax Number	:	512-916-1639

Provider Business Practice Location Address
First Line	:	7906 BRODIE LANE
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78749
Country	:	US
Telephone Number	:	512-916-1632
Fax Number	:	512-916-1639

Authorized Official
Title or Position	:	CEO
Name	:	MR. DENNIS R LATIMER
Credential	:
Telephone Number	:	512-916-1632

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/22/2020

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