Basic Information
| Provider Information | |||||||||
| NPI: | 1700831161 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER CARE PROFESSIONALS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 WEBB DR | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338373962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635881424 | ||||||||
| FaxNumber: | 8636465252 | ||||||||
| Practice Location | |||||||||
| Address1: | 4725 US HIGHWAY 98 S | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338124334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636469191 | ||||||||
| FaxNumber: | 8636465252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 05/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | SETTEMBRINO | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 8636469191 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | ME0072440 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | P00328830 | 01 | FL | RAILROAD MEDICARE | OTHER | 251631400 | 05 | FL | MEDICAID |