Provider Demographics
NPI:1679941181
Name:PREMIUM CARE USA, LLC
Entity type:Organization
Organization Name:PREMIUM CARE USA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:IVER
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, RN, CDP
Authorized Official - Phone:571-620-7556
Mailing Address - Street 1:10300 EATON PL STE 260
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2255
Mailing Address - Country:US
Mailing Address - Phone:571-620-7556
Mailing Address - Fax:571-620-7557
Practice Address - Street 1:10300 EATON PL STE 260
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2255
Practice Address - Country:US
Practice Address - Phone:571-620-7556
Practice Address - Fax:571-620-7557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-14
Last Update Date:2023-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1679941181Medicaid
VA1679941181Medicaid