Provider Demographics
NPI:1275233611
Name:PREMIUM LIFE MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:PREMIUM LIFE MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMIREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-395-3443
Mailing Address - Street 1:639 BEAVER RUIN RD NW STE A
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3473
Mailing Address - Country:US
Mailing Address - Phone:678-395-3443
Mailing Address - Fax:770-837-2426
Practice Address - Street 1:639 BEAVER RUIN RD NW STE A
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3473
Practice Address - Country:US
Practice Address - Phone:678-395-3443
Practice Address - Fax:770-837-2426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care