Healthcare Provider Details

I. General information

NPI: 1598015968
Provider Name (Legal Business Name): URBAN MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 JACKSON ST.
MONROE LA
71202-2532
US

IV. Provider business mailing address

1910 JACKSON ST.
MONROE LA
71202-2532
US

V. Phone/Fax

Practice location:
  • Phone: 318-325-7998
  • Fax: 318-398-0888
Mailing address:
  • Phone: 318-325-7998
  • Fax: 318-398-0888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KERMIT LAMAR WALTERS JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 318-325-7998