Provider Demographics
NPI:1255578803
Name:PREMIUM LIFE CARE, INC.,
Entity type:Organization
Organization Name:PREMIUM LIFE CARE, INC.,
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MECHELL
Authorized Official - Middle Name:A
Authorized Official - Last Name:VIEIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-548-8811
Mailing Address - Street 1:3220 S HIGUERA ST
Mailing Address - Street 2:SUITE 315
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6987
Mailing Address - Country:US
Mailing Address - Phone:805-548-8811
Mailing Address - Fax:805-715-3460
Practice Address - Street 1:3220 S HIGUERA ST
Practice Address - Street 2:SUITE 315
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6987
Practice Address - Country:US
Practice Address - Phone:805-548-8811
Practice Address - Fax:805-242-0676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-18
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550003349OtherSTATE HOME HEALTH AGENCY LICENSE