Provider Demographics
NPI:1578560801
Name:PREMIER HOME HEALTH LLC
Entity Type:Organization
Organization Name:PREMIER HOME HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:765-662-4091
Mailing Address - Street 1:504 N BRADNER AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2477
Mailing Address - Country:US
Mailing Address - Phone:765-662-0491
Mailing Address - Fax:765-662-0498
Practice Address - Street 1:504 N BRADNER AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2477
Practice Address - Country:US
Practice Address - Phone:765-662-0491
Practice Address - Fax:765-662-0498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010001-1251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200132560AMedicaid
IN15-7504Medicare ID - Type UnspecifiedHHA