Basic Information
| Provider Information | |||||||||
| NPI: | 1043520570 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAPITOL CONVENIENT CARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE CLINIC AT WALMART AUGUSTA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 CIVIC CENTER DR | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043308033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076208570 | ||||||||
| FaxNumber: | 2076208578 | ||||||||
| Practice Location | |||||||||
| Address1: | 174 KENNEDY MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049015134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003950232 | ||||||||
| FaxNumber: | 2078613281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2010 | ||||||||
| LastUpdateDate: | 10/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | BITHER | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | V.P. FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2078613000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.