Healthcare Provider Details

I. General information

NPI: 1245583749
Provider Name (Legal Business Name): CASTAIC URGENT CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2012
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31905 CASTAIC ROAD
CASTAIC CA
91384
US

IV. Provider business mailing address

31905 CASTAIC ROAD
CASTAIC CA
91384
US

V. Phone/Fax

Practice location:
  • Phone: 661-294-0700
  • Fax: 661-294-0701
Mailing address:
  • Phone: 661-294-0700
  • Fax: 661-294-0701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberG82000
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. LEE JACKSON JR.
Title or Position: COO / OWNER
Credential:
Phone: 805-253-6708