Provider Demographics
NPI:1811337876
Name:PREMIUM COMMUNITY CLINIC LLC
Entity type:Organization
Organization Name:PREMIUM COMMUNITY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:MARRERO MELENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-444-4211
Mailing Address - Street 1:PO BOX 51881
Mailing Address - Street 2:
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00950-1881
Mailing Address - Country:US
Mailing Address - Phone:787-444-4211
Mailing Address - Fax:787-791-6273
Practice Address - Street 1:4X2 AVE NOGAL
Practice Address - Street 2:LOMAS VERDES
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-2967
Practice Address - Country:US
Practice Address - Phone:787-444-4211
Practice Address - Fax:787-791-6273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-04
Last Update Date:2013-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4021902OtherDRIVER LICENSE