Healthcare Provider Details

I. General information

NPI: 1043448848
Provider Name (Legal Business Name): URGENT CARE BANKS CROSSING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 08/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 B POTTERY FACTORY DR
COMMERCE GA
30529-6682
US

IV. Provider business mailing address

PO BOX 1055 415 B POTTERY FACTORY DR
COMMERCE GA
30529-0020
US

V. Phone/Fax

Practice location:
  • Phone: 706-336-0074
  • Fax: 706-336-0079
Mailing address:
  • Phone: 706-336-0074
  • Fax: 706-336-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number049138
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number049138
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number049138
License Number StateGA

VIII. Authorized Official

Name: LISA A BROOKSHIRE
Title or Position: OFFICE MANAGER
Credential:
Phone: 706-336-0074