Provider Demographics
NPI:1659846293
Name:PREMIER SPORTS MEDICINE, INC.
Entity Type:Organization
Organization Name:PREMIER SPORTS MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-262-0801
Mailing Address - Street 1:35670 KENAI SPUR HWY STE 104
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7649
Mailing Address - Country:US
Mailing Address - Phone:907-262-0801
Mailing Address - Fax:907-262-0860
Practice Address - Street 1:35670 KENAI SPUR HWY STE 104
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7649
Practice Address - Country:US
Practice Address - Phone:907-262-0801
Practice Address - Fax:907-262-0860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty