MEDICARE: PREMIER SERVICE OF CAROLINA, INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center
3	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1467082396
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER SERVICE OF CAROLINA, INC

Provider Business Mailing Address
First Line	:	929 CONCORD PKWY S STE K
Second Line	:
City	:	CONCORD
State	:	NC
Zip	:	28027-5031
Country	:	US
Telephone Number	:	704-985-1189
Fax Number	:

Provider Business Practice Location Address
First Line	:	510 W KING ST
Second Line	:
City	:	KINGS MOUNTAIN
State	:	NC
Zip	:	28086-3310
Country	:	US
Telephone Number	:	704-750-4222
Fax Number	:

Authorized Official
Title or Position	:	OWNER, CEO
Name	:	WARNER LEAK
Credential	:
Telephone Number	:	704-985-1189

Provider Enumeration Date	:	01/20/2020
Last Update Date	:	08/28/2024

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