MEDICARE: PREMIER DIAGNOSTIC CENTER

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	305R00000X	Preferred Provider Organization
2	101Y00000X	Counselor

General Provider Information

NPI Number	:	1942664420
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER DIAGNOSTIC CENTER

Provider Business Mailing Address
First Line	:	9723 HOMESTEAD RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77016-4403
Country	:	US
Telephone Number	:	832-506-8121
Fax Number	:	800-918-6970

Provider Business Practice Location Address
First Line	:	9723 HOMESTEAD RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77016-4403
Country	:	US
Telephone Number	:	832-506-8121
Fax Number	:	800-918-6970

Authorized Official
Title or Position	:	COUNSELING
Name	:	ZACHERY WEST
Credential	:	LMSW
Telephone Number	:	832-506-8121

Provider Enumeration Date	:	04/11/2016
Last Update Date	:	04/11/2016

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