Basic Information
| Provider Information | |||||||||
| NPI: | 1033502141 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIUM URGENT CARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PREMIUM URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2021 HERNDON AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CLOVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936116101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597974315 | ||||||||
| FaxNumber: | 5593218730 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 SHAW AVE | ||||||||
| Address2: | STE. 105 | ||||||||
| City: | CLOVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936114072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594723534 | ||||||||
| FaxNumber: | 5597974675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2015 | ||||||||
| LastUpdateDate: | 05/02/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | ERICK | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5597974315 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.