Provider Demographics
NPI:1649977398
Name:PREMIUM LABS LLC
Entity type:Organization
Organization Name:PREMIUM LABS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERTATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KEYANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-398-9500
Mailing Address - Street 1:6729 TWO NOTCH RD STE 130
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-7535
Mailing Address - Country:US
Mailing Address - Phone:803-398-9500
Mailing Address - Fax:
Practice Address - Street 1:6729 TWO NOTCH RD STE 130
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-7535
Practice Address - Country:US
Practice Address - Phone:803-398-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service