Basic Information
| Provider Information | |||||||||
| NPI: | 1942696455 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIUM URGENT CARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PREMIUM URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2021 HERNDON AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CLOVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936116101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597974315 | ||||||||
| FaxNumber: | 5593218730 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 N CLOVIS AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937272617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594128847 | ||||||||
| FaxNumber: | 5594128447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2015 | ||||||||
| LastUpdateDate: | 05/02/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | ERICK | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5597974315 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | CA109622 | 01 | CA | PREMIUM URGENT CARE GRP PTAN | OTHER |