Provider Demographics
NPI:1235859869
Name:PREMIUM RESIDENTIAL LLC
Entity Type:Organization
Organization Name:PREMIUM RESIDENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KESIENA
Authorized Official - Middle Name:
Authorized Official - Last Name:ERUOTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:346-754-4511
Mailing Address - Street 1:3545 N CINNABAR PL
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122
Mailing Address - Country:US
Mailing Address - Phone:346-754-4511
Mailing Address - Fax:
Practice Address - Street 1:3545 N CINNABAR PL
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122
Practice Address - Country:US
Practice Address - Phone:346-754-4511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health