Provider Demographics
NPI:1053971937
Name:PREMIUM MEDICAL CENTER CORP
Entity type:Organization
Organization Name:PREMIUM MEDICAL CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:DEIVYS
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ OLIVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-334-5047
Mailing Address - Street 1:6405 NW 36TH ST STE 111
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6977
Mailing Address - Country:US
Mailing Address - Phone:786-334-5047
Mailing Address - Fax:786-334-5048
Practice Address - Street 1:6405 NW 36TH ST STE 111
Practice Address - Street 2:
Practice Address - City:VIRGINIA GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33166-6977
Practice Address - Country:US
Practice Address - Phone:786-334-5047
Practice Address - Fax:786-334-5048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-13
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty