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NPI Code Detail

MEDICARE: PREMIER CARE OF WISCONSIN, LLC.

MEDICARE: PREMIER CARE OF WISCONSIN, 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
1101YA0400XAddiction (Substance Use Disorder) Counselor
2251S00000XCommunity/Behavioral Health Agency
3261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)
4261QR0405XSubstance Use Disorder Rehabilitation Clinic/Center
5261QM2800XMethadone Clinic

General Provider Information

NPI Number : 1720701949
Entity Type Code : Organization
Provider Name (Legal Business Name) : PREMIER CARE OF WISCONSIN, LLC.
Provider Business Mailing Address
First Line : 8444 N 90TH ST STE 100
Second Line :
City : SCOTTSDALE
State : AZ
Zip : 85258-4437
Country : US
Telephone Number : 602-248-8886
Fax Number : 480-687-7361
Provider Business Practice Location Address
First Line : 4802 E BROADWAY
Second Line :
City : MADISON
State : WI
Zip : 53716-4141
Country : US
Telephone Number : 608-889-7500
Fax Number : 480-687-7361
Authorized Official
Title or Position : VICE PRESIDENT REVENUE CYCLE MGMT
Name : CINDY GAITHER
Credential :
Telephone Number : 602-248-8886
Provider Enumeration Date : 09/22/2022
Last Update Date : 02/10/2024

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