Healthcare Provider Details

I. General information

NPI: 1881819464
Provider Name (Legal Business Name): ROLLA URGENT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 09/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 S BISHOP AVE
ROLLA MO
65401-4411
US

IV. Provider business mailing address

PO BOX 817
CAPE GIRARDEAU MO
63702-0817
US

V. Phone/Fax

Practice location:
  • Phone: 573-426-5900
  • Fax: 573-426-4466
Mailing address:
  • Phone: 314-989-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number124268
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2002009086
License Number State

VIII. Authorized Official

Name: MR. OLUYOMI O OLUSANYA
Title or Position: OWNER/DEL. OFFICIAL
Credential: MD
Phone: 573-426-5900