Provider Demographics
NPI:1558929752
Name:PREMIUM HEALTH GROUP CLINIC LLC
Entity Type:Organization
Organization Name:PREMIUM HEALTH GROUP CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LUZ
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-253-1101
Mailing Address - Street 1:LAGUNA GARDENS SHOPPING CENTER
Mailing Address - Street 2:SUITE 101A
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00979
Mailing Address - Country:US
Mailing Address - Phone:787-444-4908
Mailing Address - Fax:
Practice Address - Street 1:LAGUNA GARDENS SHOPPING CENTER
Practice Address - Street 2:SUITE 101A
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00979
Practice Address - Country:US
Practice Address - Phone:787-444-4908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIUM HEALTH GROUP CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-03
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty