Provider Demographics
NPI:1699824318
Name:PREMIER COMMUNITY LIVING
Entity Type:Organization
Organization Name:PREMIER COMMUNITY LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBERMANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-987-2649
Mailing Address - Street 1:1013 MARIANA DR
Mailing Address - Street 2:
Mailing Address - City:WAKE VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75501-6212
Mailing Address - Country:US
Mailing Address - Phone:903-832-2975
Mailing Address - Fax:
Practice Address - Street 1:1013 MARIANA DR
Practice Address - Street 2:
Practice Address - City:WAKE VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:75501-6212
Practice Address - Country:US
Practice Address - Phone:903-832-2975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities