Provider Demographics
| NPI: | 1619854346 |
|---|---|
| Name: | PREMIUM NATION ENTERPRISE LLC |
| Entity type: | Organization |
| Organization Name: | PREMIUM NATION ENTERPRISE LLC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | OWNER |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | CHELKIE |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | DOUGLAS |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 281-905-4487 |
| Mailing Address - Street 1: | 20226 CHULA VISTA DR |
| Mailing Address - Street 2: | |
| Mailing Address - City: | CYPRESS |
| Mailing Address - State: | TX |
| Mailing Address - Zip Code: | 77433-8352 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 281-905-4487 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 20226 CHULA VISTA DR |
| Practice Address - Street 2: | |
| Practice Address - City: | CYPRESS |
| Practice Address - State: | TX |
| Practice Address - Zip Code: | 77433-8352 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 281-905-4487 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2025-08-15 |
| Last Update Date: | 2025-08-16 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | |
| No | 251S00000X | Agencies | Community/Behavioral Health | |
| No | 253Z00000X | Agencies | In Home Supportive Care | |
| No | 261QA0600X | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
| No | 261QD1600X | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
| No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
| No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
| No | 3104A0630X | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Behavioral Disturbances |
| No | 315P00000X | Nursing & Custodial Care Facilities | Intermediate Care Facility, Intellectual Disabilities | |
| No | 320600000X | Residential Treatment Facilities | Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
| No | 320800000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
