Provider Demographics
NPI:1346898418
Name:PREMIERCARE MEDICAL CLINIC
Entity Type:Organization
Organization Name:PREMIERCARE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DNP
Authorized Official - Prefix:
Authorized Official - First Name:EKEOMA
Authorized Official - Middle Name:I
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:D-NURSE PRACTITIONER
Authorized Official - Phone:972-373-4191
Mailing Address - Street 1:6500 NORTHWEST DR STE 350
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-1364
Mailing Address - Country:US
Mailing Address - Phone:972-373-4191
Mailing Address - Fax:972-373-4569
Practice Address - Street 1:6500 NORTHWEST DR STE 350
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-1364
Practice Address - Country:US
Practice Address - Phone:972-373-4191
Practice Address - Fax:972-373-4569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-30
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX408711601Medicaid