Provider Demographics
NPI:1417180043
Name:PREMIER LIFE HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:PREMIER LIFE HEALTH SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAURICE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-892-3627
Mailing Address - Street 1:PO BOX 702382
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34770-2382
Mailing Address - Country:US
Mailing Address - Phone:407-892-3627
Mailing Address - Fax:407-892-3625
Practice Address - Street 1:4737 OLD CANOE CREEK ROAD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-0000
Practice Address - Country:US
Practice Address - Phone:407-892-3627
Practice Address - Fax:407-892-3625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-31
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty