Basic Information
| Provider Information | |||||||||
| NPI: | 1043821218 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER CARDIOVASCULAR CARE & WELLNESS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3440 TORINGDON WAY STE 205 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282773191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046356071 | ||||||||
| FaxNumber: | 9802211956 | ||||||||
| Practice Location | |||||||||
| Address1: | 4707 SOUTH BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282172117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046356071 | ||||||||
| FaxNumber: | 8556553374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2020 | ||||||||
| LastUpdateDate: | 08/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | WASHINGTON | ||||||||
| AuthorizedOfficialFirstName: | TREVINA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7046356071 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PREMIER CARDIOVASCULAR CARE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 08/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.