Provider Demographics
NPI:1679992523
Name:PREMIERE HEALTH AND WELLNESS MEDICAL CENTER PLLC
Entity type:Organization
Organization Name:PREMIERE HEALTH AND WELLNESS MEDICAL CENTER PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:VENUS
Authorized Official - Middle Name:IDETTE
Authorized Official - Last Name:PITTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-416-4700
Mailing Address - Street 1:2609 N DUKE ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-3048
Mailing Address - Country:US
Mailing Address - Phone:919-416-4700
Mailing Address - Fax:919-416-0821
Practice Address - Street 1:608 JACKSON ST
Practice Address - Street 2:SUITE H
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-2600
Practice Address - Country:US
Practice Address - Phone:919-416-4700
Practice Address - Fax:919-416-0821
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIERE HEALTH AND WELLNESS MEDICAL CENTER, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-08
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89136E4Medicaid
NC2026035AOtherMEDICARE ID
NC89136E4Medicaid