Provider Demographics
NPI:1952025942
Name:ODESSA PREMIUM CARE
Entity Type:Organization
Organization Name:ODESSA PREMIUM CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:GIL
Authorized Official - Last Name:LLANES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-985-1399
Mailing Address - Street 1:620 N GRANT AVE STE 903
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4547
Mailing Address - Country:US
Mailing Address - Phone:702-376-2485
Mailing Address - Fax:
Practice Address - Street 1:620 N GRANT AVE STE 903
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4547
Practice Address - Country:US
Practice Address - Phone:702-376-2485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty