Provider Demographics
NPI:1982379590
Name:PREMIUM HEALTHCARE LLC
Entity Type:Organization
Organization Name:PREMIUM HEALTHCARE LLC
Other - Org Name:PERSONIC WOUND CARE OF NV
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-901-3011
Mailing Address - Street 1:11340 LAKEFIELD DR STE 200
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-2456
Mailing Address - Country:US
Mailing Address - Phone:571-833-0330
Mailing Address - Fax:
Practice Address - Street 1:8000 TOWERS CRESCENT DR STE 1392
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-6207
Practice Address - Country:US
Practice Address - Phone:571-833-0330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-16
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty