Provider Demographics
NPI:1447899448
Name:PREMIER MEDICAL GROUP LLC
Entity type:Organization
Organization Name:PREMIER MEDICAL GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-963-6363
Mailing Address - Street 1:2555 MONTESSOURI ST STE A
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-3058
Mailing Address - Country:US
Mailing Address - Phone:702-963-6363
Mailing Address - Fax:702-537-8900
Practice Address - Street 1:1050 S RAINBOW BLVD STE 210
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-6231
Practice Address - Country:US
Practice Address - Phone:702-623-8810
Practice Address - Fax:702-926-8822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-23
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No332900000XSuppliersNon-Pharmacy Dispensing Site
No343800000XTransportation ServicesSecured Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250007335Medicaid