Provider Demographics
NPI:1053710590
Name:PREMIER HEALTH & WELLNESS, LLC
Entity type:Organization
Organization Name:PREMIER HEALTH & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GODBOLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-795-9980
Mailing Address - Street 1:11801 N TATUM BLVD STE 128
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1620
Mailing Address - Country:US
Mailing Address - Phone:602-388-1343
Mailing Address - Fax:602-795-9984
Practice Address - Street 1:11801 N TATUM BLVD STE 128
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1620
Practice Address - Country:US
Practice Address - Phone:602-795-9980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty