Provider Demographics
NPI:1386694479
Name:PREMIERE OXYGEN, LLC
Entity type:Organization
Organization Name:PREMIERE OXYGEN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:K
Authorized Official - Last Name:WENDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-883-2004
Mailing Address - Street 1:3107 N DEER RUN RD
Mailing Address - Street 2:STE. 14
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89701
Mailing Address - Country:US
Mailing Address - Phone:775-883-2004
Mailing Address - Fax:775-884-4550
Practice Address - Street 1:3107 N DEER RUN RD
Practice Address - Street 2:STE. 14
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-2406
Practice Address - Country:US
Practice Address - Phone:775-883-2004
Practice Address - Fax:775-884-4550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMP00369332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100509520Medicaid
NV5706600001Medicare NSC