Basic Information
| Provider Information | |||||||||
| NPI: | 1003366063 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER REVENUE SOLUTIONS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1155 S CONGRESS AVE STE C | ||||||||
| Address2: | |||||||||
| City: | PALM SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334065114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617661300 | ||||||||
| FaxNumber: | 5616930539 | ||||||||
| Practice Location | |||||||||
| Address1: | 1155 S CONGRESS AVE STE C | ||||||||
| Address2: | |||||||||
| City: | PALM SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334065114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617661300 | ||||||||
| FaxNumber: | 5616930539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2016 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5617661300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251X00000X | Y | Agencies | Supports Brokerage |
No ID Information.