Provider Demographics
NPI:1811273642
Name:PREMIUM ASSISTED CARE
Entity type:Organization
Organization Name:PREMIUM ASSISTED CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER (OWNER)
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-808-6070
Mailing Address - Street 1:333 LOMA ALTA DR
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-3185
Mailing Address - Country:US
Mailing Address - Phone:214-808-6070
Mailing Address - Fax:
Practice Address - Street 1:549 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-5618
Practice Address - Country:US
Practice Address - Phone:214-808-6070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX978967170OtherUNITED HEALTHCARE