Provider Demographics
NPI:1609201235
Name:PREMIUM CHOICE CARE LLC
Entity Type:Organization
Organization Name:PREMIUM CHOICE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:FERDINAND
Authorized Official - Middle Name:MBAANIK
Authorized Official - Last Name:FONDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-239-6149
Mailing Address - Street 1:1949 GENEVA AVE N STE 1983
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-4108
Mailing Address - Country:US
Mailing Address - Phone:651-239-6149
Mailing Address - Fax:651-772-3357
Practice Address - Street 1:1983 GENEVA AVE N STE 1983
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-4108
Practice Address - Country:US
Practice Address - Phone:651-239-6149
Practice Address - Fax:651-772-3357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-13
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN698669300020251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health