Provider Demographics
NPI:1275203028
Name:PREMISE HEALTH OF WEST VIRGINIA MEDICAL, MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PREMISE HEALTH OF WEST VIRGINIA MEDICAL, MEDICAL CORPORATION
Other - Org Name:PREMISE HEALTH WELLNESS CENTER - LOUISVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-479-9063
Mailing Address - Street 1:5500 MARYLAND WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10000 BROWNSBORO RD STE 7
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-3900
Practice Address - Country:US
Practice Address - Phone:502-272-0330
Practice Address - Fax:502-272-0332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-14
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty