Healthcare Provider Details

I. General information

NPI: 1144694571
Provider Name (Legal Business Name): PINE KNOB URGENT CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6310 SASHABAW RD SUITE C
CLARKSTON MI
48346-2270
US

IV. Provider business mailing address

6310 SASHABAW RD SUITE C
CLARKSTON MI
48346-2270
US

V. Phone/Fax

Practice location:
  • Phone: 810-262-9020
  • Fax: 810-715-5005
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SCOTT BONZHEIM
Title or Position: PARTNER
Credential: PA-C
Phone: 810-262-9020