Basic Information
| Provider Information | |||||||||
| NPI: | 1437496791 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | URGENT CARES OF AMERICA NORTH CAROLINA INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FASTMED URGENT CARE OF WINSTON-SALEM OLD COUNTRY CLUB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5626 OBERLIN DR | ||||||||
| Address2: | 110 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211705 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4937 OLD COUNTRY CLUB ROAD | ||||||||
| Address2: | |||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365461666 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2013 | ||||||||
| LastUpdateDate: | 01/07/2013 | ||||||||
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| AuthorizedOfficialLastName: | HEINE | ||||||||
| AuthorizedOfficialFirstName: | KENNY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OPS | ||||||||
| AuthorizedOfficialTelephone: | 8589641508 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDVANTX, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 0010-02693 | NC | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.