Provider Demographics
NPI:1366821365
Name:PROFESSIONAL PREMIUM SERVICES INC
Entity Type:Organization
Organization Name:PROFESSIONAL PREMIUM SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YESDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-414-2523
Mailing Address - Street 1:2470 WINDY HILL RD SE
Mailing Address - Street 2:NUM 366C
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8613
Mailing Address - Country:US
Mailing Address - Phone:404-414-2523
Mailing Address - Fax:404-393-8880
Practice Address - Street 1:2470 WINDY HILL RD SE
Practice Address - Street 2:NUM 366C
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8613
Practice Address - Country:US
Practice Address - Phone:404-414-2523
Practice Address - Fax:404-393-8880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-22
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service