Provider Demographics
NPI:1043451446
Name:PREMIER HEALTHCARE MEDICAL GROUP
Entity Type:Organization
Organization Name:PREMIER HEALTHCARE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORENA
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-778-7772
Mailing Address - Street 1:8301 S VERMONT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-3470
Mailing Address - Country:US
Mailing Address - Phone:323-778-7772
Mailing Address - Fax:323-789-2673
Practice Address - Street 1:8301 S VERMONT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-3470
Practice Address - Country:US
Practice Address - Phone:323-778-7772
Practice Address - Fax:323-789-2673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-13
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42472207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1548216674Medicare NSC