Provider Demographics
NPI:1114378312
Name:PREMISE HEALTH
Entity Type:Organization
Organization Name:PREMISE HEALTH
Other - Org Name:THE LIVING WELL HEALTH CENTER - TOBACCOVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR SITE OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-401-1175
Mailing Address - Street 1:475 SUMMIT SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-1485
Mailing Address - Country:US
Mailing Address - Phone:336-377-3979
Mailing Address - Fax:
Practice Address - Street 1:7855 DORAL DR
Practice Address - Street 2:
Practice Address - City:TOBACCOVILLE
Practice Address - State:NC
Practice Address - Zip Code:27050-9002
Practice Address - Country:US
Practice Address - Phone:336-741-1319
Practice Address - Fax:336-714-1803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12514333600000X
3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160658OtherPK