Basic Information
| Provider Information | |||||||||
| NPI: | 1326292897 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER HEALTHCARE SERVICES, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | AVEANNA HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 INTERSTATE NORTH PKWY SE STE 1600 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303395047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702488740 | ||||||||
| FaxNumber: | 6262047950 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 THE CITY DR S | ||||||||
| Address2: | SUITE 390 | ||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148341442 | ||||||||
| FaxNumber: | 7146197666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2008 | ||||||||
| LastUpdateDate: | 03/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITESIDE | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, REGULATORY LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 7702488740 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 550000829 | CA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 1134306970 | 01 | CA | MEDICARE CMS 855A REQUIREMENT | OTHER |