Basic Information
Provider Information | |||||||||
NPI: | 1538526462 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | US MED URGENT CARE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | US MED KAPOLEI | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1245 KUALA ST | ||||||||
Address2: | SUITE 103 | ||||||||
City: | PEARL CITY | ||||||||
State: | HI | ||||||||
PostalCode: | 967823900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8084562273 | ||||||||
FaxNumber: | 8084562274 | ||||||||
Practice Location | |||||||||
Address1: | 890 KAMOKILA BLVD | ||||||||
Address2: | SUITE 102 | ||||||||
City: | KAPOLEI | ||||||||
State: | HI | ||||||||
PostalCode: | 967072022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8087842273 | ||||||||
FaxNumber: | 8087842274 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/22/2016 | ||||||||
LastUpdateDate: | 10/25/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHMIDT | ||||||||
AuthorizedOfficialFirstName: | DONNA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8084562273 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | US MED URGENT CARE, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.