MEDICARE: URGENT CARE OF WALLACE, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1699372243
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	URGENT CARE OF WALLACE, PLLC

Provider Business Mailing Address
First Line	:	4350 NC HWY 11
Second Line	:
City	:	WILLARD
State	:	NC
Zip	:	28478-7006
Country	:	US
Telephone Number	:	910-290-0561
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 MEDICAL VILLAGE DR STE G
Second Line	:
City	:	WALLACE
State	:	NC
Zip	:	28466-1665
Country	:	US
Telephone Number	:	910-285-4100
Fax Number	:

Authorized Official
Title or Position	:	BILLING SPECIALIST
Name	:	ERICA SMITH
Credential	:
Telephone Number	:	910-285-4100

Provider Enumeration Date	:	10/07/2020
Last Update Date	:	10/07/2020

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