Provider Demographics
NPI:1700654167
Name:PREMIUM PRIMARY CARE & WALK-IN CLINIC INC
Entity Type:Organization
Organization Name:PREMIUM PRIMARY CARE & WALK-IN CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:A
Authorized Official - Last Name:VERGEL DE DIOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-446-0950
Mailing Address - Street 1:1801 SE HILLMOOR DR UNIT A-107P
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7553
Mailing Address - Country:US
Mailing Address - Phone:772-446-0950
Mailing Address - Fax:772-446-0956
Practice Address - Street 1:1801 SE HILLMOOR DR UNIT A-107P
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7553
Practice Address - Country:US
Practice Address - Phone:772-446-0950
Practice Address - Fax:772-446-0956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty