Provider Demographics
NPI:1841709458
Name:PREMIER PROFESSIOAL GROUP, LLC
Entity type:Organization
Organization Name:PREMIER PROFESSIOAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-509-6776
Mailing Address - Street 1:3806 DRIFTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-3435
Mailing Address - Country:US
Mailing Address - Phone:419-509-6776
Mailing Address - Fax:
Practice Address - Street 1:5025 GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-1855
Practice Address - Country:US
Practice Address - Phone:419-509-6776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Multi-Specialty