Provider Demographics
NPI:1174695449
Name:PREMIUM CARE DOCTORS CORP.
Entity type:Organization
Organization Name:PREMIUM CARE DOCTORS CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:ALFREDO
Authorized Official - Last Name:GALGUERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-805-0012
Mailing Address - Street 1:1816 E 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-3115
Mailing Address - Country:US
Mailing Address - Phone:305-805-0012
Mailing Address - Fax:305-883-9003
Practice Address - Street 1:1816 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-3115
Practice Address - Country:US
Practice Address - Phone:305-805-0012
Practice Address - Fax:305-883-9003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258699100Medicaid