Provider Demographics
NPI:1245645928
Name:PREMIER OPTIMAL HEALTH LLC
Entity type:Organization
Organization Name:PREMIER OPTIMAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DORIA
Authorized Official - Middle Name:LAW
Authorized Official - Last Name:DEVARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-291-9108
Mailing Address - Street 1:2492 FARNSWORTH LN
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-5945
Mailing Address - Country:US
Mailing Address - Phone:847-291-9108
Mailing Address - Fax:
Practice Address - Street 1:150 N RIVER RD STE 230
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1299
Practice Address - Country:US
Practice Address - Phone:847-420-8345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-21
Last Update Date:2014-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty