Provider Demographics
NPI:1083157440
Name:PREMIERCARE @HOME LLC
Entity Type:Organization
Organization Name:PREMIERCARE @HOME LLC
Other - Org Name:PREMIERCARE ATHOME LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNERD
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-288-2638
Mailing Address - Street 1:302 N WESTBERRY ST
Mailing Address - Street 2:
Mailing Address - City:SYLVESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31791-2125
Mailing Address - Country:US
Mailing Address - Phone:229-288-2638
Mailing Address - Fax:
Practice Address - Street 1:302 N WESTBERRY ST
Practice Address - Street 2:
Practice Address - City:SYLVESTER
Practice Address - State:GA
Practice Address - Zip Code:31791-2125
Practice Address - Country:US
Practice Address - Phone:229-288-2638
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA159-R-1694251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health