Provider Demographics
NPI:1770016115
Name:PREMIER NEURO THERAPY LLC
Entity type:Organization
Organization Name:PREMIER NEURO THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-357-2349
Mailing Address - Street 1:13700 SUTTON PARK DR N
Mailing Address - Street 2:APT. 816
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-2273
Mailing Address - Country:US
Mailing Address - Phone:904-470-0673
Mailing Address - Fax:
Practice Address - Street 1:14255 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250-1576
Practice Address - Country:US
Practice Address - Phone:904-470-0673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty