Provider Demographics
NPI:1871115279
Name:PREMIUM HEALTH GROUP CLINIC LLC
Entity type:Organization
Organization Name:PREMIUM HEALTH GROUP CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUZ
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-253-1101
Mailing Address - Street 1:LAGUNA GARDENS SHOPPING CENTER
Mailing Address - Street 2:SUITE 101-A
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00979
Mailing Address - Country:US
Mailing Address - Phone:787-791-7287
Mailing Address - Fax:
Practice Address - Street 1:LAGUNA GARDENS SHOPPING CENTER
Practice Address - Street 2:SUITE 101-A
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00979
Practice Address - Country:US
Practice Address - Phone:787-791-7287
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service