Provider Demographics
NPI:1174886956
Name:PREMIERTOX 2 0 LLC
Entity type:Organization
Organization Name:PREMIERTOX 2 0 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:A
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-368-9504
Mailing Address - Street 1:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40602-1038
Mailing Address - Country:US
Mailing Address - Phone:502-226-3858
Mailing Address - Fax:502-223-9829
Practice Address - Street 1:3221 SUMMIT SQUARE PL
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2653
Practice Address - Country:US
Practice Address - Phone:859-368-9504
Practice Address - Fax:859-368-9503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK098240Medicare PIN