Basic Information
| Provider Information | |||||||||
| NPI: | 1710209234 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAMPSON REGIONAL PROFESSIONAL SERVICES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLINTON URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 890315 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282890315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105928511 | ||||||||
| FaxNumber: | 9105925461 | ||||||||
| Practice Location | |||||||||
| Address1: | 1004 BEAMAN ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283282329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105929113 | ||||||||
| FaxNumber: | 9105900050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2010 | ||||||||
| LastUpdateDate: | 08/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | BALLTZGLIER | ||||||||
| AuthorizedOfficialFirstName: | HUNTER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9105908755 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 99999 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | 99999 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | 99999 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.