Provider Demographics
NPI:1780825547
Name:PREMIUM CARE MEDICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:PREMIUM CARE MEDICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:CLUKIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-659-2502
Mailing Address - Street 1:104 N EVERS ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-3300
Mailing Address - Country:US
Mailing Address - Phone:813-659-2502
Mailing Address - Fax:
Practice Address - Street 1:104 N EVERS ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-3300
Practice Address - Country:US
Practice Address - Phone:813-659-2502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty