Basic Information
| Provider Information | |||||||||
| NPI: | 1881819464 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROLLA URGENT CARE LLC | ||||||||
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| OtherOrganizationName: | ROLLA URGENT CARE RURAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 817 | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637020817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149890300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1060 S BISHOP AVE | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654014411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734265900 | ||||||||
| FaxNumber: | 5734264466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 09/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | OLUSANYA | ||||||||
| AuthorizedOfficialFirstName: | OLUYOMI | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/DEL. OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5734265900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ROLLA URGENT CARE LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 363L00000X | 124268 | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | 2002009086 | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.