MEDICARE: PREMIUM GROUP CENTER, 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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1982655569
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIUM GROUP CENTER, INC.

Provider Business Mailing Address
First Line	:	4445 W 16TH AVE
Second Line	:	600
City	:	HIALEAH
State	:	FL
Zip	:	33012-7189
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4445 W 16TH AVE
Second Line	:	600
City	:	HIALEAH
State	:	FL
Zip	:	33012-7189
Country	:	US
Telephone Number	:	786-000-0000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. CARIDAD CORVEA
Credential	:
Telephone Number	:	786-000-0000

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	07/21/2022

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Directions to “PREMIUM GROUP CENTER, INC. ” Practice Location

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