Provider Demographics
NPI:1306506340
Name:PREMIER WELLNESS
Entity type:Organization
Organization Name:PREMIER WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DYNAE
Authorized Official - Middle Name:CHERE
Authorized Official - Last Name:POFAHL
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:308-440-2678
Mailing Address - Street 1:124 W 46TH ST STE 206
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-8348
Mailing Address - Country:US
Mailing Address - Phone:308-440-2678
Mailing Address - Fax:
Practice Address - Street 1:124 W 46TH ST STE 206
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-8348
Practice Address - Country:US
Practice Address - Phone:308-440-2678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty