Basic Information
| Provider Information | |||||||||
| NPI: | 1558764464 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER HEALTH & WELLNESS CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14149 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708984149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259300060 | ||||||||
| FaxNumber: | 2259529075 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 HIGHLAND BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | NATCHEZ | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391204600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013042421 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2014 | ||||||||
| LastUpdateDate: | 03/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | WALLER | ||||||||
| AuthorizedOfficialFirstName: | ANGIE | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | FNP | ||||||||
| AuthorizedOfficialTelephone: | 6013042421 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | FNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | R853759 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.