1689971822 NPI number — PREMIER MEDICAL, INC.

Table of content: DR. CARLOS V. RIVERA DMD (NPI 1669694121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689971822 NPI number — PREMIER MEDICAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER MEDICAL, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689971822
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26897
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29616-1897
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-679-2957
Provider Business Mailing Address Fax Number:
800-207-7401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6000A PELHAM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-335-2455
Provider Business Practice Location Address Fax Number:
877-889-9157
Provider Enumeration Date:
02/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MURDOCK
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
877-335-2455

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: 20928 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 018150600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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