Provider Demographics
NPI:1932345410
Name:PREMIER HEALTHCARE OF PLACERVILLE
Entity Type:Organization
Organization Name:PREMIER HEALTHCARE OF PLACERVILLE
Other - Org Name:PREMIER HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:530-622-3536
Mailing Address - Street 1:1980 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-9001
Mailing Address - Country:US
Mailing Address - Phone:530-622-3536
Mailing Address - Fax:530-622-3538
Practice Address - Street 1:1980 BROADWAY
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-9001
Practice Address - Country:US
Practice Address - Phone:530-622-3536
Practice Address - Fax:530-622-3538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-05
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55172208VP0000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6309300001Medicare NSC
CABZ709AMedicare PIN