Provider Demographics
NPI:1336599547
Name:PREMIUM WELLNESS AND PRIMARY CARE
Entity Type:Organization
Organization Name:PREMIUM WELLNESS AND PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:DIANNE
Authorized Official - Last Name:ZELLOUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-553-0793
Mailing Address - Street 1:4002 SPRING GARDEN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-1683
Mailing Address - Country:US
Mailing Address - Phone:336-553-0793
Mailing Address - Fax:
Practice Address - Street 1:4002 SPRING GARDEN ST
Practice Address - Street 2:SUITE C
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1683
Practice Address - Country:US
Practice Address - Phone:336-553-0793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-18
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004483261QH0100X
NC5006433261QH0100X
363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8975633Medicaid
NC8975633Medicaid