1942696455 NPI number — PREMIUM URGENT CARE, INC.

Table of content: (NPI 1942696455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942696455 NPI number — PREMIUM URGENT CARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIUM URGENT CARE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PREMIUM URGENT CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942696455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2021 HERNDON AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CLOVIS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93611-6101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-797-4315
Provider Business Mailing Address Fax Number:
559-321-8730

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 N CLOVIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93727-2617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-412-8847
Provider Business Practice Location Address Fax Number:
559-412-8447
Provider Enumeration Date:
04/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
ERICK
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
559-797-4315

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CA109622 . This is a "PREMIUM URGENT CARE GRP PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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