MEDICARE: PREMIUM LABS LLC

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	305S00000X	Point of Service

General Provider Information

NPI Number	:	1649977398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIUM LABS LLC

Provider Business Mailing Address
First Line	:	6729 TWO NOTCH RD STE 130
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-7535
Country	:	US
Telephone Number	:	803-398-9500
Fax Number	:

Provider Business Practice Location Address
First Line	:	6729 TWO NOTCH RD STE 130
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-7535
Country	:	US
Telephone Number	:	803-398-9500
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERTATIONS
Name	:	KEYANNE HOLMES
Credential	:
Telephone Number	:	803-398-9500

Provider Enumeration Date	:	02/13/2023
Last Update Date	:	02/13/2023

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