Provider Demographics
NPI:1598959736
Name:PREMIER FAMILY LIFE & TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:PREMIER FAMILY LIFE & TREATMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DELOIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-931-9973
Mailing Address - Street 1:1314 W EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-4726
Mailing Address - Country:US
Mailing Address - Phone:580-931-9973
Mailing Address - Fax:580-924-1176
Practice Address - Street 1:1314 W EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-4726
Practice Address - Country:US
Practice Address - Phone:580-931-9973
Practice Address - Fax:580-924-1176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3445251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health