Provider Demographics
NPI:1417350828
Name:PREMIUM SELECT
Entity Type:Organization
Organization Name:PREMIUM SELECT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HHA
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SEAWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-718-0504
Mailing Address - Street 1:4303 F ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-4253
Mailing Address - Country:US
Mailing Address - Phone:202-718-0504
Mailing Address - Fax:
Practice Address - Street 1:4303 F ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-4253
Practice Address - Country:US
Practice Address - Phone:202-718-0504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA5982261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care