Healthcare Provider Details

I. General information

NPI: 1871816884
Provider Name (Legal Business Name): PROVIDENCE IMMEDIATE CARE INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2010
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 OVERLOOK DR
VILLA RICA GA
30180-5804
US

IV. Provider business mailing address

1002 OVERLOOK DR
VILLA RICA GA
30180-5804
US

V. Phone/Fax

Practice location:
  • Phone: 678-907-2086
  • Fax: 678-840-8742
Mailing address:
  • Phone: 678-907-2086
  • Fax: 678-840-8742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. EWANE NGONE
Title or Position: PRESIDENT/CEO
Credential: M.D.
Phone: 678-907-2086