Provider Demographics
NPI:1295419158
Name:MOMPREMIER, CHRIS ZACK
Entity type:Individual
Prefix:
First Name:CHRIS
Middle Name:ZACK
Last Name:MOMPREMIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 DANIEL AVE
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33971-5655
Mailing Address - Country:US
Mailing Address - Phone:239-745-9812
Mailing Address - Fax:
Practice Address - Street 1:2303 DANIEL AVE
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-5655
Practice Address - Country:US
Practice Address - Phone:239-745-9812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLM516-119-00-132-0106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician