Provider Demographics
NPI:1811433444
Name:PREMIER SERVICE OF CAROLINA, INC
Entity type:Organization
Organization Name:PREMIER SERVICE OF CAROLINA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-985-1189
Mailing Address - Street 1:109 PENNY ST
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-2803
Mailing Address - Country:US
Mailing Address - Phone:704-985-1189
Mailing Address - Fax:
Practice Address - Street 1:207 N BOONE ST STE 300
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5675
Practice Address - Country:US
Practice Address - Phone:704-985-1189
Practice Address - Fax:704-985-1189
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER SERVICE OF CAROLINA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-06
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNI000000019328251S00000X
TNI000000021371251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ021696Medicaid