Provider Demographics
NPI:1184163644
Name:PREMIEREMED LLC
Entity type:Organization
Organization Name:PREMIEREMED LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:S
Authorized Official - Last Name:CLEMENTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-203-8512
Mailing Address - Street 1:1664 ANDERSON HWY STE B
Mailing Address - Street 2:
Mailing Address - City:POWHATAN
Mailing Address - State:VA
Mailing Address - Zip Code:23139-8056
Mailing Address - Country:US
Mailing Address - Phone:804-314-8890
Mailing Address - Fax:804-956-3152
Practice Address - Street 1:1664 ANDERSON HWY STE B
Practice Address - Street 2:
Practice Address - City:POWHATAN
Practice Address - State:VA
Practice Address - Zip Code:23139-8056
Practice Address - Country:US
Practice Address - Phone:804-203-8512
Practice Address - Fax:804-956-3152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-16
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0206010019332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0206010019OtherDME LICENSE