1508471418 NPI number — WATERLOO URGENT CARE WALK IN CLINIC COMPANY

Table of content: (NPI 1508471418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508471418 NPI number — WATERLOO URGENT CARE WALK IN CLINIC COMPANY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WATERLOO URGENT CARE WALK IN CLINIC COMPANY
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:
Provider Other Organization Name Type Code:
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:
1508471418
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14671 TELEGRAPH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDFORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48239-3300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
131-394-8305
Provider Business Mailing Address Fax Number:
313-948-3041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 ILLINOIS ROUTE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERLOO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62298
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-948-3055
Provider Business Practice Location Address Fax Number:
248-250-6430
Provider Enumeration Date:
09/09/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MOLNAR
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS OPERATIONS MANAGER
Authorized Official Telephone Number:
313-948-3055

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)





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