Basic Information
| Provider Information | |||||||||
| NPI: | 1962817601 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | APPLECARE MEMORIAL IMMEDIATE CARE JOINT VENTURE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 671447 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752671447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123502121 | ||||||||
| FaxNumber: | 9123502145 | ||||||||
| Practice Location | |||||||||
| Address1: | 14089 ABERCORN ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314191966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123502121 | ||||||||
| FaxNumber: | 9123502145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2014 | ||||||||
| LastUpdateDate: | 03/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | HASH | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9123509335 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 003148665A | 05 | GA | MEDICAID |