Basic Information
Provider Information | |||||||||
NPI: | 1124218847 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PREMIER FAMILY CARE I, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2501 W. ILLINOIS | ||||||||
Address2: | SUITE C | ||||||||
City: | MIDLAND | ||||||||
State: | TX | ||||||||
PostalCode: | 797016433 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4326866600 | ||||||||
FaxNumber: | 4326822284 | ||||||||
Practice Location | |||||||||
Address1: | 1900 W. WALL | ||||||||
Address2: | SUITE A | ||||||||
City: | MIDLAND | ||||||||
State: | TX | ||||||||
PostalCode: | 797016534 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4324982900 | ||||||||
FaxNumber: | 4324982990 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/30/2007 | ||||||||
LastUpdateDate: | 11/14/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEJIL | ||||||||
AuthorizedOfficialFirstName: | LEAH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4326866605 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 018061401 | 01 | TX | MEDICAID EPSDT# | OTHER |