Provider Demographics
NPI:1982655569
Name:PREMIUM GROUP CENTER, INC.
Entity Type:Organization
Organization Name:PREMIUM GROUP CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARIDAD
Authorized Official - Middle Name:
Authorized Official - Last Name:CORVEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-000-0000
Mailing Address - Street 1:4445 W 16TH AVE
Mailing Address - Street 2:600
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4445 W 16TH AVE
Practice Address - Street 2:600
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7189
Practice Address - Country:US
Practice Address - Phone:786-000-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center